Nebivolol and its metabolites in combination with nitric oxide donors, compositions and methods of use

ABSTRACT

The invention describes novel compositions comprising nebivolol and/or at least one metabolite of nebivolol and at least one nitric oxide donor, and, optionally, at least one antioxidant or a pharmaceutically acceptable salt thereof, and/or at least one compound used to treat cardiovascular diseases or a pharmaceutically acceptable salt thereof, and/or at least one nitrosated compound used to treat cardiovascular diseases. The compounds and compositions of the invention can also be bound to a matrix. The nitric oxide donor is a compound that donates, transfers or releases nitric oxide, elevates endogenous levels of endothelium-derived relaxing factor, stimulates endogenous synthesis of nitric oxide or is a substrate for nitric oxide synthase and may preferably be isosorbide dinitrate and/or isosorbide mononitrate. The antioxidant may preferably be a hydralazine compound or a pharmaceutically acceptable salt thereof. The invention also provides methods for treating and/or preventing vascular diseases characterized by nitric oxide insufficiency; and for treating and/or preventing Raynaud&#39;s syndrome; and for treating and/or preventing cardiovascular diseases or disorders.

RELATED APPLICATIONS

This application is a divisional under 35 USC § 121 of U.S. applicationSer. No. 10/695,644, filed Oct. 29, 2003, now U.S. Pat. No. 7,138,430which claims priority under 35 USC § 120 to PCT/US02/13667, filed May 1,2002, which claims priority under 35 USC § 119 to U.S. ProvisionalApplication No. 60/287,725 filed May 2, 2001.

FIELD OF THE INVENTION

The invention describes novel nitrosated and/or nitrosylated nebivolol,novel nitrosated and/or nitrosylated metabolites of nebivolol and novelcompositions comprising at least one nitrosated and/or nitrosylatednebivolol and/or at least one nitrosated and/or nitrosylated metaboliteof nebivolol, and, optionally, at least one nitric oxide donor and/or atleast one antioxidant or a pharmaceutically acceptable salt thereof,and/or at least one compound used to treat cardiovascular diseases or apharmaceutically acceptable salt thereof, and/or at least one nitrosatedcompound used to treat cardiovascular diseases. The invention alsoprovides novel compositions comprising nebivolol and/or at least onemetabolite of nebivolol and at least one nitric oxide donor, and,optionally, at least one antioxidant or a pharmaceutically acceptablesalt thereof, and/or at least one compound used to treat cardiovasculardiseases or a pharmaceutically acceptable salt thereof, and/or at leastone nitrosated compound used to treat cardiovascular diseases. Thecompounds and compositions of the invention can also be bound to amatrix. The nitric oxide donor is a compound that donates, transfers orreleases nitric oxide, elevates endogenous levels of endothelium-derivedrelaxing factor, stimulates endogenous synthesis of nitric oxide or is asubstrate for nitric oxide synthase and may preferably be isosorbidedinitrate and/or isosorbide mononitrate. The antioxidant may preferablybe a hydralazine compound or a pharmaceutically acceptable salt thereof.The invention also provides methods for treating and/or preventingvascular diseases characterized by nitric oxide insufficiency; and fortreating and/or preventing Raynaud's syndrome; and for treating and/orpreventing cardiovascular diseases or disorders.

BACKGROUND OF THE INVENTION

The decline in cardiovascular morbidity and mortality in the UnitedStates over the past three decades has been the result of significantadvances in research on cardiovascular disease mechanisms andtherapeutic strategies. The incidence and prevalence of myocardialinfarction and death from myocardial infarction, as well as that fromcerebrovascular accident, have decreased significantly over this periodlargely owing to advances in prevention, early diagnosis, and treatmentof these very common diseases.

Analysis of outcomes by race, however, paints quite a different picture:life expectancy and cardiovascular morbidity rates have improved farless for blacks than whites. Available data show that the likelihood ofdying from cardiovascular disease is far greater among black Americansthan among white Americans. In this decade, the death rate fromcardiovascular disease for black males was 353 per 100,000 population,while that for white males was 244 per 100,000; the rate for blackfemales was 226 per 100,000; while that for white females was 135 per100,000. Consonant with this important demographic parameter is theobservation that there is a higher prevalence of several of theimportant risk factors for cardiovascular disease, e.g., hypertension,smoking, diabetes mellitus, obesity, and left ventricular hypertrophy,among blacks compared with whites. In addition, outcomes ofcardiovascular events are worse for blacks than whites. Followingmyocardial infarction, blacks have a 50% higher annual mortality ratethan whites, and their five-year survival is only 70%. Thus, the manyadvances in cardiovascular medicine that account for the overallimprovement in cardiovascular health in the general population hasfailed to translate into comparable racial benefits.

There is a need in the art for new and more effective compositions andmethods for treating vascular diseases. The invention is directed tothese, as well as other, important ends.

SUMMARY OF THE INVENTION

The invention describes novel nitrosated and/or nitrosylated nebivolol,novel nitrosated and/or nitrosylated metabolites of nebivolol andmethods of treating and/or preventing vascular diseases characterized bynitric oxide insufficiency, and Raynaud's syndrome by administering atleast one nitrosated and/or nitrosylated nebivolol and/or at least onenitrosated and/or nitrosylated metabolite of nebivolol that is capableof releasing a therapeutically effective amount of nitric oxide to atargeted site effected by the vascular disease.

One embodiment of the invention provides novel nitrosated and/ornitrosylated nebivolol and/or novel nitrosated and/or nitrosylatedmetabolites of nebivolol. The nebivolol and/or its metabolites can benitrosated and/or nitrosylated through one or more sites such as oxygen(hydroxyl condensation), sulfur (sulfhydryl condensation) and/ornitrogen. The invention also provides compositions comprising atherapeutically effective amount of such compounds in a pharmaceuticallyacceptable carrier.

Another embodiment of the invention provides compositions comprising atherapeutically effective amount of nebivolol that is optionallysubstituted with at least one NO and/or NO₂ group (i.e., nitrosylatedand/or nitrosated), and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and at least one compound that donates,transfers or releases nitrogen monoxide as a charged species, i.e.,nitrosonium (NO⁺) or nitroxyl (NO−), or as the neutral species, nitricoxide (NO•), and/or stimulates endogenous production of nitric oxide orEDRF in vivo and/or is a substrate for nitric oxide synthase. The nitricoxide donor may preferably be isosorbide dinitrate and/or isosorbidemononitrate. The invention also provides for such compositions in apharmaceutically acceptable carrier.

Yet another embodiment of the invention provides compositions comprisinga therapeutically effective of nebivolol that is optionally substitutedwith at least one NO and/or NO₂ group (i.e., nitrosylated and/ornitrosated), and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and at least one antioxidant, and,optionally, at least one compound that donates, transfers or releasesnitrogen monoxide as a charged species, i.e., nitrosonium (NO⁺) ornitroxyl (NO−), or as the neutral species, nitric oxide (NO•), and/orstimulates endogenous production of nitric oxide or EDRF in vivo and/oris a substrate for nitric oxide synthase. The antioxidant may preferablybe a hydralazine compound or a pharmaceutically acceptable salt thereof.The nitric oxide donor may preferably be isosorbide dinitrate and/orisosorbide mononitrate. The invention also provides for suchcompositions in a pharmaceutically acceptable carrier.

Another embodiment of the invention provides compositions comprising atherapeutically effective amount of nebivolol that is optionallysubstituted with at least one NO and/or NO₂ group (i.e., nitrosylatedand/or nitrosated), and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and, optionally, at least oneantioxidant, and/or at least one compound that donates, transfers orreleases nitrogen monoxide as a charged species, i.e., nitrosonium (NO⁺)or nitroxyl (NO−), or as the neutral species, nitric oxide (NO•), and/orstimulates endogenous production of nitric oxide or EDRF in vivo and/oris a substrate for nitric oxide synthase and/or at least one compoundused to treat cardiovascular diseases, optionally substituted with atleast one NO₂ group (i.e., nitrosated). The antioxidant may preferablybe a hydralazine compound or a pharmaceutically acceptable salt thereof.The nitric oxide donor may preferably be isosorbide dinitrate and/orisosorbide mononitrate. The invention also provides for suchcompositions in a pharmaceutically acceptable carrier.

The invention provides methods for treating and/or preventing vasculardiseases characterized by nitric oxide insufficiency by administering toa patient a therapeutically effective amount of nebivolol that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and/or at least one metabolite ofnebivolol, that is optionally substituted with at least one NO and/orNO₂ group (i.e. nitrosylated and/or nitrosated), and, optionally, atleast one compound that donates, transfers or releases nitric oxide,elevates endogenous levels of endothelium-derived relaxing factor,stimulates endogenous synthesis of nitric oxide or is a substrate fornitric oxide synthase, and/or at least one antioxidant or apharmaceutically acceptable salt thereof, and/or at least one compoundused to treat cardiovascular diseases, or a pharmaceutically acceptablesalt thereof, optionally substituted with at least one NO₂ group (i.e.,nitrosated). The nitric oxide donor may preferably be isosorbidedinitrate and/or isosorbide mononitrate. The antioxidant may preferablybe a hydralazine compound or a pharmaceutically acceptable salt thereof.The nebivolol and/or the metabolite of nebivolol and optional nitricoxide donor compound, antioxidant, and/or compound used to treatcardiovascular diseases can be administered separately or as componentsof the same composition in one or more pharmaceutically acceptablecarriers.

In another embodiment, the invention provides methods for treatingand/or preventing Raynaud's syndrome by administering to a patient atherapeutically effective amount of nebivolol that is optionallysubstituted with at least one NO and/or NO₂ group (i.e., nitrosylatedand/or nitrosated), and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and, optionally, at least one compoundthat donates, transfers or releases nitric oxide, elevates endogenouslevels of endothelium-derived relaxing factor, stimulates endogenoussynthesis of nitric oxide or is a substrate for nitric oxide synthase,and/or at least one antioxidant or a pharmaceutically acceptable saltthereof, and/or at least one compound used to treat cardiovasculardiseases that is optionally substituted with at least one NO₂ group(i.e., nitrosated). The nitric oxide donor may preferably be isosorbidedinitrate and/or isosorbide mononitrate. The antioxidant may preferablybe a hydralazine compound or a pharmaceutically acceptable salt thereof.The nebivolol and/or metabolite of nebivolol and optional nitric oxidedonor compound, antioxidant, and/or compound used to treatcardiovascular diseases can be administered separately or as componentsof the same composition in one or more pharmaceutically acceptablecarriers.

Another embodiment of the invention describes compositions and methodsfor making compositions comprising nebivolol that is optionallysubstituted with at least one NO and/or NO₂ group (i.e., nitrosylatedand/or nitrosated), and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group (i.e.,nitrosylated and/or nitrosated), and, optionally, at least one compoundthat donates, transfers or releases nitric oxide and/or stimulatesendogenous production of nitric oxide or EDRF in vivo and/or is asubstrate for nitric oxide synthase, that are bound to a natural orsynthetic matrix, which can be applied with specificity to a biologicalsite of interest. For example, the matrix containing the nitrosatedand/or nitrosylated nebivolol can be used to coat the surface of amedical device or instrument that comes into contact with blood(including blood components, blood products and the like) or vasculartissue.

Another embodiment of the invention also provides methods foradministering to a patient in need thereof a therapeutically effectiveamount of nebivolol and/or at least one metabolite of nebivolol and atleast one compound that donates, transfers or releases nitric oxide as acharged species, i.e., nitrosonium (NO⁺) or nitroxyl (NO−), or as theneutral species, nitric oxide (NO•), and/or stimulates endogenousproduction of nitric oxide or EDRF in vivo and/or is a substrate fornitric oxide synthase for treating and/or preventing cardiovasculardiseases or disorders. The methods can further comprise administering atherapeutically effective amount of at least one therapeutic agent.Alternatively, the methods for treating and/or preventing cardiovasculardiseases or disorders, can comprise administering a therapeuticallyeffective amount of at nebivolol and/or at least one metabolite ofnebivolol, at least one therapeutic agent, and, optionally, at least onecompound that donates, transfers or releases nitric oxide as a chargedspecies, i.e., nitrosonium (NO⁺) or nitroxyl (NO−), or as the neutralspecies, nitric oxide (NO•), and/or stimulates endogenous production ofnitric oxide or EDRF in vivo and/or is a substrate for nitric oxidesynthase. The nebivolol, the metabolite of nebivolol, the nitric oxidedonors, and the therapeutic agents can be administered separately or ascomponents of the same composition in one or more pharmaceuticallyacceptable carriers.

Yet another embodiment of the invention describes methods for theprevention of platelet aggregation and platelet adhesion caused by theexposure of blood to a medical device or instrument by incorporating atleast one nitrosated and/or nitrosylated nebivolol and/or at least onemetabolite of nebivolol that is capable of releasing a therapeuticallyeffective amount of nitric oxide into and/or on the portion(s) of themedical device that come into contact with blood (including bloodcomponents and blood products) or vascular tissue. The methods canfurther comprise incorporating at least one compound that donates,transfers or releases nitric oxide, and/or stimulates endogenousproduction of nitric oxide or EDRF in vivo and/or is a substrate fornitric oxide synthase, and, optionally, at least one therapeutic agentinto and/or on the portion(s) of the medical device that come intocontact with blood or vascular tissue. Alternatively the methods cancomprise incorporating nebivolol and/or at least one metabolite ofnebivolol and at least one NO donor, and, optionally, at least onetherapeutic agent into and/or on the portion(s) of the medical devicethat comes into contact with blood or vascular tissue.

Another embodiment of the invention relates to the local administrationof nebivolol that is optionally substituted with at least one NO and/orNO₂ group, and/or at least one metabolite of nebivolol, that isoptionally substituted with at least one NO and/or NO₂ group, and,optionally, at least one therapeutic agent and/or at least one nitricoxide donor, to treat injured tissue, such as damaged blood vessels.

These and other aspects of the invention are described in detail herein.The following drawings are illustrative of embodiments of the inventionand do not limit the scope of the invention as defined by the claims.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is the synthetic scheme for the preparation of nitrite containingcompounds of Formula (I).

FIG. 2 is the synthetic scheme for the preparation of nitrosothiolcontaining compounds of Formula (I).

FIG. 3 is the synthetic scheme for the preparation of nitrate containingcompounds of Formula (I).

FIG. 4 is the synthetic scheme for the preparation of2-hydroxy-2-nitrosohydrazine containing compounds of Formula (I).

FIG. 5 is the synthetic scheme for the preparation of nitrite containingcompounds of Formula (II).

FIG. 6 is the synthetic scheme for the preparation of nitrosothiolcontaining compounds of Formula (II).

FIG. 7 is the synthetic scheme for the preparation of nitrate containingcompounds of Formula (II).

FIG. 8 is the synthetic scheme for the preparation of2-hydroxy-2-nitrosohydrazine containing compounds of Formula (II).

FIG. 9 is the synthetic scheme for the preparation of nitrite containingcompounds of Formula (III).

FIG. 10 is the synthetic scheme for the preparation of nitritecontaining compounds of Formula (III).

FIG. 11 is the synthetic scheme for the preparation of nitrosothiolcontaining compounds of Formula (III).

FIG. 12 is the synthetic scheme for the preparation of nitrosothiolcontaining compounds of Formula (III).

FIG. 13 is the synthetic scheme for the preparation of nitratecontaining compounds of Formula (III).

FIG. 14 is the synthetic scheme for the preparation of nitratecontaining compounds of Formula (III).

FIG. 15 is the synthetic scheme for the preparation of2-hydroxy-2-nitrosohydrazine containing compounds of Formula (III).

FIG. 16 is the synthetic scheme for the preparation of2-hydroxy-2-nitrosohydrazine containing compounds of Formula (III).

DETAILED DESCRIPTION OF THE INVENTION

As used throughout the disclosure, the following terms, unless otherwiseindicated, shall be understood to have the following meanings.

“Patient” refers to animals, preferably mammals, most preferably humans,and includes males and females.

“Therapeutically effective amount” refers to the amount of the compoundand/or composition that is effective to achieve its intended purpose.

“Hydrazino” refers to H₂N—N(H)—.

“Hydralazine compound” refers to a compound having the Formula (VI):

wherein a, b and c are independently a single or double bond; R₇ and R₈are each independently a hydrogen, an alkyl, an ester or a heterocyclicring; R₉ and R₁₀ are each independently a lone pair of electrons or ahydrogen, with the proviso that at least one of R₇, R₈, R₉ and R₁₀ isnot a hydrogen. Exemplary hydralazine compounds include budralazine,cadralazine, dihydralazine, endralazine, hydralazine, pildralazine,todralazine, and the like.

“Compound used to treat cardiovascular diseases” refers to anytherapeutic compound, or a pharmaceutically acceptable salt thereof,used to treat any cardiovascular disease.

“Vascular diseases characterized by nitric oxide insufficiency” include,but are not limited to, cardiovascular diseases; diseases resulting fromoxidative stress; hypertension (e.g., low-renin hypertension;salt-sensitive hypertension; low-renin, salt-sensitive hypertension;primary pulmonary hypertension; thromboembolic pulmonary hypertension;pregnancy-induced hypertension; renovascular hypertension,hypertension-dependent end-stage renal disease), heart failure (e.g.,microvascular cardiac ischemia), and left ventricular hypertrophy withdisproportionate microvascularization, (i.e., inadequate vascularity) ordiastolic dysfunction.

“Cardiovascular diseases” refers to any cardiovascular disease ordisorder known in the art, including, but not limited to, congestiveheart failure, hypertension, pulmonary hypertension, myocardial andcerebral infarctions, atherosclerosis, atherogenesis, thrombosis,ischemic heart disease, post-angioplasty restenosis, coronary arterydiseases, renal failure, stable, unstable and variant (Prinzmetal)angina, cardiac edema, renal insufficiency, nephrotic edema, hepaticedema, stroke, transient ischemic attacks, cerebrovascular accidents,restenosis, controlling blood pressure in hypertension (especiallyhypertension associated with cardiovascular surgical procedures),platelet adhesion, platelet aggregation, smooth muscle cellproliferation, pulmonary edema associated with acute myocardialinfarction, vascular complications associated with the use of medicaldevices, wounds associated with the use of medical devices, pulmonarythromboembolism, cerebral thromboembolism, thrombophlebitis,thrombocytopenia, bleeding disorders, and the like. Complicationsassociated with the use of medical devices may occur as a result ofincreased platelet deposition, activation, thrombus formation orconsumption of platelets and coagulation proteins. Such complications,which are within the definition of “cardiovascular disease or disorder,”include, for example, myocardial infarction, pulmonary thromboembolism,cerebral thromboembolism, thrombophlebitis, thrombocytopenia, bleedingdisorders and/or any other complications which occur either directly orindirectly as a result of the foregoing disorders.

“Restenosis” is a cardiovascular disease or disorder that refers to theclosure of a peripheral or coronary artery following trauma to theartery caused by an injury such as, for example, angioplasty, balloondilation, atherectomy, laser ablation treatment or stent insertion. Forthese angioplasty procedures, restenosis occurs at a rate of about30-60% depending upon the vessel location, lesion length and a number ofother variables. Restenosis can also occur following a number ofinvasive surgical techniques, such as, for example, transplant surgery,vein grafting, coronary artery bypass surgery, endarterectomy, hearttransplantation, ballon angioplasty, atherectomy, laser ablation,endovascular stenting, and the like.

“Atherosclerosis” is a form of chronic vascular injury in which some ofthe normal vascular smooth muscle cells in the artery wall, whichordinarily control vascular tone regulating blood flow, change theirnature and develop “cancer-like” behavior. These vascular smooth musclecells become abnormally proliferative, secreting substances such asgrowth factors, tissue-degradation enzymes and other proteins, whichenable them to invade and spread into the inner vessel lining, blockingblood flow and making that vessel abnormally susceptible to beingcompletely blocked by local blood clotting, resulting in the death ofthe tissue served by that artery.

“Diseases resulting from oxidative stress” refers to any disease thatinvolves the generation of free radicals or radical compounds, such as,for example, atherogenesis, atheromatosis, arteriosclerosis,artherosclerosis, vascular hypertrophy associated with hypertension,hyperlipoproteinaemia, normal vascular degeneration through aging,parathyroidal reactive hyperplasia, chronic renal disease, neoplasticdiseases, inflammatory diseases, neurological and acute bronchopulmonarydisease, tumorigenesis, ischemia-reperfusion syndrome, arthritis,sepsis, and the like.

“Therapeutic agent” includes any therapeutic agent that can inhibit thecellular activity of a vascular smooth muscle cell, for example,proliferation, migration, increase in cell volume, increase inextracellular matrix synthesis (e.g., collagens, proteoglycans, and thelike), or secretion of extracellular matrix materials by the cell,biologically stenting a vessel and/or reduce or inhibit vascularremodeling and/or inhibit or reduce vascular smooth muscle proliferationfollowing a procedural vascular trauma. Although nitric oxide donorshave therapeutic activity, the term “therapeutic agent” does not includethe nitric oxide donors described herein, since nitric oxide donors areseparately defined.

“Artificial surface” refers to any natural or synthetic materialcontained in a device or apparatus that is in contact with blood,vasculature or other tissues.

“Blood” includes blood products, blood components and the like.

“Platelet adhesion” refers to the contact of a platelet with a foreignsurface, including any artificial surface, such as a medical device orinstrument, as well as an injured vascular surfaces, such as collagen.Platelet adhesion does not require platelet activation. Unactivated,circulating platelets will adhere to injured vascular surfaces orartificial surfaces via binding interactions between circulating vonWilldebrand factor and platelet surface glycoprotein Ib/IX.

“Platelet aggregation” refers to the binding of one or more platelets toeach other. Platelet aggregation is commonly referred to in the contextof generalized atherosclerosis, not with respect to platelet adhesion onvasculature damaged as a result of physical injury during a medicalprocedure. Platelet aggregation requires platelet activation, whichdepends on the interaction between the ligand and its specific plateletsurface receptor.

“Platelet activation” refers either to the change in conformation(shape) of a cell, expression of cell surface proteins (e.g., theIIb/IIIa receptor complex, loss of GPIb surface protein), and secretionof platelet derived factors (e.g., serotonin, growth factors).

“Passivation” refers to the coating of a surface, which renders thesurface non-reactive.

“Medical device” refers to any intravascular or extravascular medicaldevices, medical instruments, foreign bodies and the like. Examples ofintravascular medical devices and instruments include balloons orcatheter tips adapted for insertion, prosthetic heart valves, sutures,synthetic vessel grafts, stents (e.g. Palmaz-Schatz stent), drug pumps,arteriovenous shunts, artificial heart valves, artificial implants,foreign bodies introduced surgically into the blood vessels or atvascular sites, leads, pacemakers, implantable pulse generators,implantable cardiac defibrillators, cardioverter defibrillators,defibrillators, spinal stimulators, brain stimulators, sacral nervestimulators, chemical sensors, and the like. Examples of extravascularmedical devices and instruments include plastic tubing, dialysis bags ormembranes whose surfaces come in contact with the blood stream of apatient.

“Transdermal” refers to the delivery of a compound by passage throughthe skin and into the blood stream.

“Transmucosal” refers to delivery of a compound by passage of thecompound through the mucosal tissue and into the blood stream.

“Penetration enhancement” or “permeation enhancement” refers to anincrease in the permeability of the skin or mucosal tissue to a selectedpharmacologically active compound such that the rate at which thecompound permeates through the skin or mucosal tissue is increased.

“Carriers” or “vehicles” refers to carrier materials suitable forcompound administration and include any such material known in the artsuch as, for example, any liquid, gel, solvent, liquid diluent,solubilizer, or the like, which is non-toxic and which does not interactwith any components of the composition in a deleterious manner.

“Sustained release” refers to the release of a therapeutically activecompound and/or composition such that the blood levels of thetherapeutically active compound are maintained within a desirabletherapeutic range over an extended period of time. The sustained releaseformulation can be prepared using any conventional method known to oneskilled in the art to obtain the desired release characteristics.

“Nitric oxide adduct” or “NO adduct” refers to compounds and functionalgroups which, under physiological conditions, can donate, release and/ordirectly or indirectly transfer any of the three redox forms of nitrogenmonoxide (NO⁺, NO⁻, NO•), such that the biological activity of thenitrogen monoxide species is expressed at the intended site of action.

“Nitric oxide releasing” or “nitric oxide donating” refers to methods ofdonating, releasing and/or directly or indirectly transferring any ofthe three redox forms of nitrogen monoxide (NO⁺, NO⁻, NO•), such thatthe biological activity of the nitrogen monoxide species is expressed atthe intended site of action.

“Nitric oxide donor” or “NO donor” refers to compounds that donate,release and/or directly or indirectly transfer a nitrogen monoxidespecies, and/or stimulate the endogenous production of nitric oxide orendothelium-derived relaxing factor (EDRF) in vivo and/or elevateendogenous levels of nitric oxide or EDRF in vivo. “NO donor” alsoincludes compounds that are substrates for nitric oxide synthase.

“Taxane” refers to any compound that contains the carbon core frameworkrepresented by Formula A:

“Alkyl” refers to a lower alkyl group, a haloalkyl group, a hydroxyalkylgroup, an alkenyl group, an alkynyl group, a bridged cycloalkyl group, acycloalkyl group or a heterocyclic ring, as defined herein. An alkylgroup may also comprise one or more radical species, such as, forexample a cycloalkylalkyl group or a heterocyclicalkyl group.

“Lower alkyl” refers to branched or straight chain acyclic alkyl groupcomprising one to about ten carbon atoms (preferably one to about eightcarbon atoms, more preferably one to about six carbon atoms). Exemplarylower alkyl groups include methyl, ethyl, n-propyl, isopropyl, n-butyl,isobutyl, sec-butyl, t-butyl, pentyl, neopentyl, iso-amyl, hexyl, octyl,and the like.

“Substituted lower alkyl” refers to a lower alkyl group, as definedherein, wherein one or more of the hydrogen atoms have been replacedwith one or more R¹⁰⁰ groups, wherein each R¹⁰⁰ is independently ahydroxy, an oxo, a carboxyl, a carboxamido, a halo, a cyano or an aminogroup, as defined herein.

“Haloalkyl” refers to a lower alkyl group, an alkenyl group, an alkynylgroup, a bridged cycloalkyl group, a cycloalkyl group or a heterocyclicring, as defined herein, to which is appended one or more halogens, asdefined herein. Exemplary haloalkyl groups include trifluoromethyl,chloromethyl, 2-bromobutyl, 1-bromo-2-chloro-pentyl, and the like.

“Alkenyl” refers to a branched or straight chain C₂-C₁₀ hydrocarbon(preferably a C₂-C₈ hydrocarbon, more preferably a C₂-C₆ hydrocarbon)that can comprise one or more carbon-carbon double bonds. Exemplaryalkenyl groups include propylenyl, buten-1-yl, isobutenyl, penten-1-yl,2,2-methylbuten-1-yl, 3-methylbuten-1-yl, hexan-1-yl, hepten-1-yl,octen-1-yl, and the like.

“Lower alkenyl” refers to a branched or straight chain C₂-C₄ hydrocarbonthat can comprise one or two carbon-carbon double bonds.

“Substituted alkenyl” refers to a branched or straight chain C₂-C₁₀hydrocarbon (preferably a C₂-C₈ hydrocarbon, more preferably a C₂-C₆hydrocarbon) which can comprise one or more carbon-carbon double bonds,wherein one or more of the hydrogen atoms have been replaced with one ormore R¹⁰⁰ groups, wherein each R¹⁰⁰ is independently a hydroxy, an oxo,a carboxyl, a carboxamido, a halo, a cyano or an amino group, as definedherein.

“Alkynyl” refers to an unsaturated acyclic C₂-C₁₀ hydrocarbon(preferably a C₂-C₈ hydrocarbon, more preferably a C₂-C₆ hydrocarbon)that can comprise one or more carbon-carbon triple bonds. Exemplaryalkynyl groups include ethynyl, propynyl, butyn-1-yl, butyn-2-yl,pentyl-1-yl, pentyl-2-yl, 3-methylbutyn-1-yl, hexyl-1-yl, hexyl-2-yl,hexyl-3-yl, 3,3-dimethyl-butyn-1-yl, and the like.

“Bridged cycloalkyl” refers to two or more saturated or unsaturatedcycloalkyl groups, saturated or unsaturated heterocyclic groups, or acombination thereof fused via adjacent or non-adjacent atoms. Bridgedcycloalkyl groups can be unsubstituted or substituted with one, two orthree substituents independently selected from alkyl, alkoxy, amino,alkylamino, dialkylamino, hydroxy, halo, carboxyl, alkylcarboxylic acid,aryl, amidyl, ester, alkylcarboxylic ester, carboxamido,alkylcarboxamido, oxo and nitro. Exemplary bridged cycloalkyl groupsinclude adamantyl, decahydronapthyl, quinuclidyl,2,6-dioxabicyclo(3.3.0)octane, 7-oxabycyclo(2.2.1)heptyl,8-azabicyclo(3,2,1)oct-2-enyl and the like.

“Cycloalkyl” refers to a saturated or unsaturated cyclic hydrocarboncomprising from about 3 to about 10 carbon atoms. Cycloalkyl groups canbe unsubstituted or substituted with one, two or three substituentsindependently selected from alkyl, alkoxy, amino, alkylamino,dialkylamino, arylamino, diarylamino, alkylarylamino, aryl, amidyl,ester, hydroxy, halo, carboxyl, alkylcarboxylic acid, alkylcarboxylicester, carboxamido, alkylcarboxamido, oxo, alkylsulfinyl, and nitro.Exemplary cycloalkyl groups include cyclopropyl, cyclobutyl,cyclopentyl, cyclohexyl, cyclohexenyl, cyclohepta-1,3-dienyl, and thelike.

“Heterocyclic ring or group” refers to a saturated or unsaturated cyclichydrocarbon group having about 2 to about 10 carbon atoms (preferablyabout 4 to about 6 carbon atoms) where 1 to about 4 carbon atoms arereplaced by one or more nitrogen, oxygen and/or sulfur atoms. Sulfurmaybe in the thio, sulfinyl or sulfonyl oxidation state. Theheterocyclic ring or group can be fused to an aromatic hydrocarbongroup. Heterocyclic groups can be unsubstituted or substituted with one,two or three substituents independently selected from alkyl, alkoxy,amino, alkylthio, aryloxy, arylthio, arylalkyl, hydroxy, oxo, thial,halo, carboxyl, carboxylic ester, alkylcarboxylic acid, alkylcarboxylicester, aryl, arylcarboxylic acid, arylcarboxylic ester, amidyl, ester,alkylcarbonyl, arylcarbonyl, alkylsulfinyl, carboxamido,alkylcarboxamido, arylcarboxamido, sulfonic acid, sulfonic ester,sulfonamido and nitro. Exemplary heterocyclic groups include pyrrolyl,furyl, thienyl, 3-pyrrolinyl,4,5,6-trihydro-2H-pyranyl, pyridinyl,1,4-dihydropyridinyl, pyrazolyl, triazolyl, pyrimidinyl, pyridazinyl,oxazolyl, thiazolyl, imidazolyl, indolyl, thiophenyl, furanyl,tetrhydrofuranyl, tetrazolyl, pyrrolinyl, pyrrolindinyl, oxazolindinyl1,3-dioxolanyl, imidazolinyl, imidazolindinyl, pyrazolinyl,pyrazolidinyl, isoxazolyl, isothiazolyl, 1,2,3-oxadiazolyl,1,2,3-triazolyl, 1,3,4-thiadiazolyl, 2H-pyranyl, 4H-pyranyl,piperidinyl, 1,4-dioxanyl, morpholinyl, 1,4-dithianyl, thiomorpholinyl,pyrazinyl, piperazinyl, 1,3,5-triazinyl, 1,3,5-trithianyl,benzo(b)thiophenyl, benzimidazolyl, benzothiazolinyl, quinolinyl, andthe like.

“Heterocyclic compounds” refer to mono- and polycyclic compoundscomprising at least one aryl or heterocyclic ring.

“Aryl” refers to a monocyclic, bicyclic, carbocyclic or heterocyclicring system comprising one or two aromatic rings. Exemplary aryl groupsinclude phenyl, pyridyl, napthyl, quinoyl, tetrahydronaphthyl, furanyl,indanyl, indenyl, indoyl, and the like. Aryl groups (including bicyclicaryl groups) can be unsubstituted or substituted with one, two or threesubstituents independently selected from alkyl, alkoxy, alkylthio,amino, alkylamino, dialkylamino, arylamino, diarylamino, alkylarylamino,halo, cyano, alkylsulfinyl, hydroxy, carboxyl, carboxylic ester,alkylcarboxylic acid, alkylcarboxylic ester, aryl, arylcarboxylic acid,arylcarboxylic ester, alkylcarbonyl, arylcarbonyl, amidyl, ester,carboxamido, alkylcarboxamido, carbomyl, sulfonic acid, sulfonic ester,sulfonamido and nitro. Exemplary substituted aryl groups includetetrafluorophenyl, pentafluorophenyl, sulfonamide, alkylsulfonyl,arylsulfonyl, and the like.

“Cycloalkenyl” refers to an unsaturated cyclic C₂-C₁₀ hydrocarbon(preferably a C₂-C₈ hydrocarbon, more preferably a C₂-C₆ hydrocarbon)which can comprise one or more carbon-carbon triple bonds.

“Arylalkyl” refers to an aryl radical, as defined herein, attached to analkyl radical, as defined herein. Exemplary arylalkyl groups includebenzyl, phenylethyl, 4-hydroxybenzyl, 3-fluorobenzyl,2-fluorophenylethyl, and the like.

“Alkylaryl” refers to an alkyl group, as defined herein, to which isappended an aryl group, as defined herein. Exemplary alkylaryl groupsinclude benzyl, phenylethyl, hydroxybenzyl, fluorobenzyl,fluorophenylethyl, and the like.

“Arylalkenyl” refers to an aryl radical, as defined herein, attached toan alkenyl radical, as defined herein. Exemplary arylalkenyl groupsinclude styryl, propenylphenyl, and the like.

“Cycloalkylalkyl” refers to a cycloalkyl radical, as defined herein,attached to an alkyl radical, as defined herein.

“Cycloalkylalkoxy” refers to a cycloalkyl radical, as defined herein,attached to an alkoxy radical, as defined herein.

“Cycloalkylalkylthio” refers to a cycloalkyl radical, as defined herein,attached to an alkylthio radical, as defined herein.

“Heterocyclicalkyl” refers to a heterocyclic ring radical, as definedherein, attached to an alkyl radical, as defined herein.

“Arylheterocyclic ring” refers to a bi- or tricyclic ring comprised ofan aryl ring, as defined herein, appended via two adjacent carbon atomsof the aryl ring to a heterocyclic ring, as defined herein. Exemplaryarylheterocyclic rings include dihydroindole,1,2,3,4-tetra-hydroquinoline, and the like.

“Alkoxy” refers to R₅₀O—, wherein R₅₀ is an alkyl group, as definedherein (preferably a lower alkyl group or a haloalkyl group, as definedherein). Exemplary alkoxy groups include methoxy, ethoxy, t-butoxy,cyclopentyloxy, trifluoromethoxy, and the like.

“Lower alkoxy” refers to a lower alkyl group, as defined herein,appended to an oxygen atom.

“Aryloxy” refers to R₅₅O—, wherein R₅₅ is an aryl group, as definedherein. Exemplary arylkoxy groups include napthyloxy, quinolyloxy,isoquinolizinyloxy, and the like.

“Alkylthio” refers to R₅₀S—, wherein R₅₀ is an alkyl group, as definedherein.

“Lower alkylthio” refers to a lower alkyl group, as defined herein,appended to a thio group, as defined herein.

“Arylalkoxy” or “alkoxyaryl” refers to an alkoxy group, as definedherein, to which is appended an aryl group, as defined herein. Exemplaryarylalkoxy groups include benzyloxy, phenylethoxy, chlorophenylethoxy,and the like.

“Alkoxyalkyl” refers to an alkoxy group, as defined herein, appended toan alkyl group, as defined herein. Exemplary alkoxyalkyl groups includemethoxymethyl, methoxyethyl, isopropoxymethyl, and the like.

“Alkoxyhaloalkyl” refers to an alkoxy group, as defined herein, appendedto a haloalkyl group, as defined herein. Exemplary alkoxyhaloalkylgroups include 4-methoxy-2-chlorobutyl and the like.

“Cycloalkoxy” refers to R₅₄O—, wherein R₅₄ is a cycloalkyl group or abridged cycloalkyl group, as defined herein. Exemplary cycloalkoxygroups include cyclopropyloxy, cyclopentyloxy, cyclohexyloxy, and thelike.

“Cycloalkylthio” refers to R₅₄S—, wherein R₅₄ is a cycloalkyl group or abridged cycloalkyl group, as defined herein. Exemplary cycloalkylthiogroups include cyclopropylthio, cyclopentylthio, cyclohexylthio, and thelike.

“Haloalkoxy” refers to an alkoxy group, as defined herein, in which oneor more of the hydrogen atoms on the alkoxy group are substituted withhalogens, as defined herein. Exemplary haloalkoxy groups include1,1,1-trichloroethoxy, 2-bromobutoxy, and the like.

“Hydroxy” refers to —OH.

“Oxo” refers to ═O.

“Oxy” refers to —O⁻R₇₇ ⁺ wherein R₇₇ is an organic or inorganic cation.

“Organic cation” refers to a positively charged organic ion. Exemplaryorganic cations include alkyl substituted ammonium cations, and thelike.

“Inorganic cation” refers to a positively charged metal ion. Exemplaryinorganic cations include Group I metal cations such as for example,sodium, potassium, and the like.

“Hydroxyalkyl” refers to a hydroxy group, as defined herein, appended toan alkyl group, as defined herein.

“Nitrate” refers to —O—NO₂.

“Nitrite” refers to —O—NO.

“Thionitrate” refers to —S—NO₂.

“Thionitrite” and “nitrosothiol” refer to —S—NO.

“Nitro” refers to the group —NO₂ and “nitrosated” refers to compoundsthat have been substituted therewith.

“Nitroso” refers to the group —NO and “nitrosylated” refers to compoundsthat have been substituted therewith.

“Nitrile” and “cyano” refer to —CN.

“Halogen” or “halo” refers to iodine (I), bromine (Br), chlorine (Cl),and/or fluorine (F).

“Amino” refers to —NH₂, an alkylamino group, a dialkylamino group, anarylamino group, a diarylamino group, an alkylarylamino group or aheterocyclic ring, as defined herein.

“Alkylamino” refers to R₅ONH—, wherein R₅₀ is an alkyl group, as definedherein. Exemplary alkylamino groups include methylamino, ethylamino,butylamino, cyclohexylamino, and the like.

“Arylamino” refers to R₅₅NH—, wherein R₅₅ is an aryl group, as definedherein.

“Dialkylamino” refers to R₅₂R₅₃N—, wherein R₅₂ and R₅₃ are eachindependently an alkyl group, as defined herein. Exemplary dialkylaminogroups include dimethylamino, diethylamino, methyl propargylamino, andthe like.

“Diarylamino” refers to R₅₅R₆₀N—, wherein R₅₅ and R₆₀ are eachindependently an aryl group, as defined herein.

“Alkylarylamino or arylalkylamino” refers to R₅₂R₅₅N—, wherein R₅₂ is analkyl group, as defined herein, and R₅₅ is an aryl group, as definedherein.

“Alkylarylalkylamino” refers to R₅₂R₇₉N—, wherein R₅₂ is an alkyl group,as defined herein, and R₇₉ is an arylalkyl group, as defined herein.

“Alkylcycloalkylamino” refers to R₅₂R₈₀N—, wherein R₅₂ is an alkylgroup, as defined herein, and R₈₀ is an cycloalkyl group, as definedherein.

“Aminoalkyl” refers to an amino group, an alkylamino group, adialkylamino group, an arylamino group, a diarylamino group, analkylarylamino group or a heterocyclic ring, as defined herein, to whichis appended an alkyl group, as defined herein. Exemplary aminoalkylgroups include dimethylaminopropyl, diphenylaminocyclopentyl,methylaminomethyl, and the like.

“Aminoaryl” refers to an aryl group to which is appended an alkylaminogroup, a arylamino group or an arylalkylamino group. Exemplary aminoarylgroups include anilino, N-methylanilino, N-benzylanilino, and the like.

“Thio” refers to —S—.

“Sulfinyl” refers to —S(O)—.

“Methanthial” refers to —C(S)—.

“Thial” refers to ═S.

“Sulfonyl” refers to —S(O)₂ ³¹ .

“Sulfonic acid” refers to —S(O)₂OR₇₆, wherein R₇₆ is a hydrogen, anorganic cation or an inorganic cation, as defined herein.

“Alkylsulfonic acid” refers to a sulfonic acid group, as defined herein,appended to an alkyl group, as defined herein.

“Arylsulfonic acid” refers to a sulfonic acid group, as defined herein,appended to an aryl group, as defined herein

“Sulfonic ester” refers to —S(O)₂OR₅₈, wherein R₅₈ is an alkyl group, anaryl group, or an aryl heterocyclic ring, as defined herein.

“Sulfonamido” refers to —S(O)₂—N(R₅₁)(R₅₇), wherein R₅, and R₅₇ are eachindependently a hydrogen atom, an alkyl group, an aryl group or anarylheterocyclic ring, as defined herein, or R₅₁ and R₅₇ taken togetherwith the nitrogen to which they are attached are a heterocyclic ring ora bridged cycloalkyl group, as defined herein.

“Alkylsulfonamido” refers to a sulfonamido group, as defined herein,appended to an alkyl group, as defined herein.

“Arylsulfonamido” refers to a sulfonamido group, as defined herein,appended to an aryl group, as defined herein.

“Alkylthio” refers to R₅₀S—, wherein R₅₀ is an alkyl group, as definedherein (preferably a lower alkyl group, as defined herein).

“Arylthio” refers to R₅₅S—, wherein R₅₅ is an aryl group, as definedherein.

“Arylalkylthio” refers to an aryl group, as defined herein, appended toan alkylthio group, as defined herein.

“Alkylsulfinyl” refers to R₅₀—S(O)—, wherein R₅₀ is an alkyl group, asdefined herein.

“Alkylsulfonyl” refers to R₅₀—S(O)₂—, wherein R₅₀ is an alkyl group, asdefined herein.

“Alkylsulfonyloxy” refers to R₅₀—S(O)₂—O—, wherein R₅₀ is an alkylgroup, as defined herein.

“Arylsulfinyl” refers to R₅₅—S(O)—, wherein R₅₅ is an aryl group, asdefined herein.

“Arylsulfonyl” refers to R₅₅—S(O)₂—, wherein R₅₅ is an aryl group, asdefined herein.

“Arylsulfonyloxy” refers to R₅₅—S(O)₂—O—, wherein R₅₅ is an aryl group,as defined herein.

“Amidyl” refers to R₅₁C(O)N(R₅₇)— wherein R₅₁ and R₅₇ are eachindependently a hydrogen atom, an alkyl group, an aryl group or anarylheterocyclic ring, as defined herein.

“Ester” refers to R₅₁C(O)O— wherein R₅₁ is a hydrogen atom, an alkylgroup, an aryl group or an arylheterocyclic ring, as defined herein.

“Carbamoyl” refers to —O—C(O)N(R₅₁)(R₅₇), wherein R₅, and R₅₇ are eachindependently a hydrogen atom, an alkyl group, an aryl group or anarylheterocyclic ring, as defined herein, or R₅₁ and R₅₇ taken togetherwith the nitrogen to which they are attached are a heterocyclic ring ora bridged cycloalkyl group, as defined herein.

“Carboxyl” refers to —C(O)OR₇₆, wherein R₇₆ is a hydrogen, an organiccation or an inorganic cation, as defined herein.

“Carbonyl” refers to —C(O)—.

“Alkylcarbonyl” refers to R₅₂—C(O)—, wherein R₅₂ is an alkyl group, asdefined herein.

“Arylcarbonyl” refers to R₅₅—C(O)—, wherein R₅₅ is an aryl group, asdefined herein.

“Arylalkylcarbonyl” refers to R₅₅—R₅₂—C(O)—, wherein R₅₅ is an arylgroup, as defined herein, and R₅₂ is an alkyl group, as defined herein.

“Alkylarylcarbonyl” refers to R₅₂—R₅₅—C(O)—, wherein R₅₅ is an arylgroup, as defined herein, and R₅₂ is an alkyl group, as defined herein.

“Heterocyclicalkylcarbonyl” refer to R₇₈C(O)— wherein R₇₈ is aheterocyclicalkyl group, as defined herein.

“Carboxylic ester” refers to —C(O)OR₅₈, wherein R₅₈ is an alkyl group,an aryl group or an aryl heterocyclic ring, as defined herein.

“Alkylcarboxylic acid” and “alkylcarboxyl” refer to an alkyl group, asdefined herein, appended to a carboxyl group, as defined herein.

“Alkylcarboxylic ester” refers to an alkyl group, as defined herein,appended to a carboxylic ester group, as defined herein.

“Arylcarboxylic acid” refers to an aryl group, as defined herein,appended to a carboxyl group, as defined herein.

“Arylcarboxylic ester” and “arylcarboxyl” refer to an aryl group, asdefined herein, appended to a carboxylic ester group, as defined herein.

“Carboxamido” refers to —C(O)N(R₅₁)(R₅₇), wherein R₅₁ and R₅₇ are eachindependently a hydrogen atom, an alkyl group, an aryl group or anarylheterocyclic ring, as defined herein, or R₅₁ and R₅₇ taken togetherwith the nitrogen to which they are attached are a heterocyclic ring ora bridged cycloalkyl group, as defined herein.

“Alkylcarboxamido” refers to an alkyl group, as defined herein, appendedto a carboxamido group, as defined herein.

“Arylcarboxamido” refers to an aryl group, as defined herein, appendedto a carboxamido group, as defined herein.

“Oxime” refers to —C(═N—OR₈₁) wherein R₈, is a hydrogen, an alkyl group,an aryl group, an alkylsulfonyl group, an arylsulfonyl group, acarboxylic ester, an alkylcarbonyl group, an arylcarbonyl group, acarboxamido group, an alkoxyalkyl group or an alkoxyaryl group.

“Urea” refers to —N(R₅₉)—C(O)N(R₅₁)(R₅₇) wherein R₅₁, R₅₇, and R₅₉ areeach independently a hydrogen atom, an alkyl group, an aryl group or anarylheterocyclic ring, as defined herein, or R₅₁ and R₅₇ taken togetherwith the nitrogen to which they are attached are a heterocyclic ring ora bridged cycloalkyl group, as defined herein.

“Phosphoryl” refers to —P(R₇₀)(R₇₁)(R₇₂), wherein R₇₀ is a lone pair ofelectrons, sulfur or oxygen, and R₇₁ and R₇₂ are each independently acovalent bond, a hydrogen, a lower alkyl, an alkoxy, an alkylamino, ahydroxy or an aryl, as defined herein.

“Silyl” refers to —Si(R₇₃)(R₇₄)(R₇₅), wherein R₇₃, R₇₄ and R₇₅ are eachindependently a covalent bond, a lower alkyl, an alkoxy, an aryl or anarylalkoxy, as defined herein.

Two broad classes of cardiovascular diseases or disorders are moreprevalent among blacks than whites and serve as areas in need ofinvestigative efforts. Hypertension and left ventricular hypertrophy,two related yet independent risk factors for coronary heart disease, aresignificantly more prevalent among blacks than whites. Blacks also havehigher rates of angiographically normal coronary arteries despite ahigher prevalence of risk factors for coronary atherosclerosis, andgreater morbidity and mortality from coronary heart disease than whites.These paradoxical observations have led some investigators to postulatethat blacks harbor a diathesis of the microvasculature that limitsperfusion and serves as a stimulus for vascular smooth muscle cell andcardiomyocyte hypertrophy, which, in turn, leads to hypertension andleft ventricular hypertrophy, respectively. The underlying basis forthis vascular diathesis may involve the endothelium, which has a limitedcapacity to generate vasodilator and antiproliferative factors or anincreased capacity to produce vasoconstrictor and proliferative factors;the vascular smooth muscle cell, which manifests increased sensitivityto vasoconstrictor and proliferative factors; or both, in theseindividuals.

A major product of the normal blood vessel that may play a role in thevascular diathesis of blacks is endothelium-derived nitric oxide (NO).Nitric oxide produced by the endothelial cells induces vascular smoothmuscle cell relaxation, contributing importantly to resting vasculartone. In addition, NO inhibits vascular smooth muscle cell proliferationand induces apoptosis in smooth muscle cells, which leads to the releaseof basic fibroblast growth factor and vascular endothelial cell growthfactor, in turn supporting endothelial cell proliferation. This sequenceof cellular responses is believed to sustain angiogenesis under hypoxicor ischemic conditions.

The role of nitric oxide in the vascular diathesis of blacks isillustrated by the consequences of nitric oxide insufficiency in thenormal responses of the vasculature to nitric oxide. Nitric oxideinsufficiency suppresses renin release from the juxtaglomerular cells,and induces a sodium chloride/volume sensitive increase in bloodpressure. Furthermore, nitric oxide insufficiency leads to an increasedsensitivity of vascular smooth muscle cells to vasoconstrictors, such asangiotensin II and catecholamines, which amplify the increase invascular resistance.

Nitric oxide insufficiency promotes vascular smooth muscle cellproliferation following vascular injury, and sustains smooth muscle celland cardiomyocyte hypertrophy in response to catecholamines andangiotensin II. Furthermore, inadequate nitric oxide leads to increasedproduction of extracellular matrix with consequent myocardial fibrosis.

These many cardiovascular responses that result from inadequate NO inthe vasculature have clear clinical correlates in the black population.The clinical vascular phenotype of blacks that distinguishes them fromwhites with similar cardiovascular diseases or disorders is one ofsalt-sensitive, low-renin hypertension; left ventricular hypertrophydisproportionate to after load and with an inadequate angiogenicresponse; and microvascular ischemia in the absence of significantepicardial coronary artery disease. The net pathophysiologicalconsequences of these effects are increased peripheral vascularresistance with accompanying arterial hypertension; and an inadequatelyvascularized, fibrotic increase in left ventricular mass withaccompanying diastolic dysfunction and microvascular ischemia.

Nitric oxide insufficiency states can be a consequence of reducedsynthesis of nitric oxide, enhanced inactivation of nitric oxide, orboth. Possible candidate mechanisms include alterations in the genesthat code for endothelial nitric oxide synthase or the induciblemicrovascular and cardiomyocyte nitric oxide synthase leading to reducedexpression of a normal gene product or appropriate expression of a lessactive gene product; reduction in the enzymatic activity of nitric oxidesynthase owing to inadequate cofactor concentrations; or enhancedinactivation of nitric oxide by oxidant stress.

Data obtained by the inventors in cultured cells, animal models, andhuman patients suggest that increased oxidant stress is central to thevascular diathesis of and consequent cardiovascular diseases ordisorders common among African Americans. Possible candidate mechanismsfor the oxidant stress include enhanced production of reactive oxygenspecies (ROS), decreased antioxidant defenses, or both. The inventorsmake no a priori assumptions about the temporal or causativerelationship between oxidant stress and the vascular phenotype ofblacks: oxidant stress may both precede the development of the vasculardiathesis and promote its progression once established. Recent datasuggest that enhanced ROS production accompanies essential hypertension,atherosclerosis, thrombosis, and diabetes mellitus, and appears in eachcase, at the very least, to be important in the progression ofestablished disease, if not in its actual genesis.

Endothelium-derived relaxing factor (EDRF), first described by Furchgottet al, Nature, 299:373-376 (1980), is an important mediator of vascularfunction. This endothelial product activates guanylyl cyclase invascular smooth muscle cells and platelets, leading to vasorelaxationand platelet inhibition, respectively (Loscalzo et al, Prog CardiovascDis, 38:87-104 (1995)). The chemical nature of EDRF has been studiedusing a variety of pharmacological and analytical techniques, and is NO(Ignarro et al, Circ Res, 61:866-879 (1987); Palmer et al, Nature,327:524-526 (1987)).

Nitric oxide is synthesized by one of several isoforms of the NOsynthase (NOS) family of enzymes, two of which are found in thevasculature, endothelial NOS (eNOS) and inducible NOS (iNOS). eNOS issynthesized by endothelial cells, while iNOS is synthesized by a varietyof cell types, including vascular smooth muscle cells, fibroblasts, and(principally microvascular) endothelial cells (Balligand et al, Am JPhysiol, 268:H1293-1303 (1995)). These enzymes produce NO as a result ofthe five-electron oxidation of L-arginine to L-citrulline; requisitecofactors include calcium-calmodulin, O₂, FAD, FMN, tetrahydrobiopterinthiols, heme, and NADPH. (Moncada et al, N EngI J Med, 329:2002-2012(1993)).

The role of NO in the cardiovascular system has become increasinglyapparent over the past fifteen years (Loscalzo et al, Prog CardiovascDis, 38:87-104 (1995)). Nitric oxide contributes importantly to restingtone in conductance as well as resistance arteries (Ouyyumi et al, JClin Invest, 95:1747-1755 (1995)), and plays a critical role in themaintenance of peripheral vascular resistance and arterial pressureresponses. Inhibition of NOS activity is associated with enhancedvascular sensitivity to vasoconstrictors, such as norepinephrine andangiotensin II (Conrad et al, Am J Physiol, 262:R1137-R1144 (1992)), andthis effect appears to be mediated, in part, by increased calciumsensitivity (Bank et al, Hypertension, 24:322-328 (1994)). Nitric oxiderelease from the cardiovascular regulatory center in the brain may alsobe involved in the central regulation of blood pressure, suggesting arole for neuronal NOS in the regulation of vascular tone (Cabrera et al,Biochem Biophys Res Comm, 206:77-81 (1995); Mattson et al, Hypertension,28:297-303 (1996)).

Nitric oxide activates renin gene expression in the kidney, and isinvolved in the baroreceptor-mediated regulation of renin geneexpression (Schricker et al, Pflug Arch, 428:261-268 (1994)). Thedependence of blood pressure on salt intake appears to depend on NO, andNO deficiency states are associated with salt-sensitivity (Tolins et al,Kidney Internat, 46:230-236 (1994)). Selective inhibition of iNOS inDahl R rats has been shown to lead to salt-sensitivity and to thedevelopment of salt-dependent hypertension similar to Dahl S rats (Ruddet al, Am J Physiol, 277: H732-H739 (1999)). In addition, mice deficientin iNOS (iNOS gene eliminated by targeted disruption) may develophypertension in response to salt feeding (Rudd et al, Circulation, 98:1A(1998)).

Nitric oxide also affects myocardial contractility, and does so both bymediating muscarinic-cholinergic slowing of the heart rate and thecontractile response to beta-adrenergic stimulation (Balligand et al,Proc Nat'l Acad Sci USA, 90:347-351 (1993)). This latter effect appearsto be mediated in vivo through the vagus nerve (Hare et al, J ClinInvest, 95:360-366 (1995)).

In both vascular smooth muscle cells and cardiomyocytes, NO inhibitscellular proliferation and limits the proliferative response togrowth-promoting substances (Garg et al, J Clin Invest, 83:1774-1777(1986)). Left ventricular hypertrophy tends to occur in adult heartswith inadequate capillary proliferation, and this may account for themicrovascular ischemia noted in patients with hypertrophy. Capillaryproliferation is generally held to be a rare event in normal adultmammalian hearts. However, recent data from a hypertensive rat model, inwhich left ventricular hypertrophy commonly occurs, show that treatmentwith a low-dose of an angiotensin-converting enzyme inhibitorinsufficient to prevent hypertension and left ventricular hypertrophycan, nonetheless, evoke capillary angiogenesis. Compared with untreatedcontrols, treatment with the angiotensin converting enzyme inhibitorincreased myocardial capillary proliferation (Unger et al, Hypertension,20:478482 (1992)), and this effect was believed to be a consequence ofinhibiting the degradation and potentiating the action of bradykinin.Bradykinin increases myocardial blood flow by inducing release of NOfrom microvascular endothelial cells, and increased blood flow is apowerful stimulus for capillary proliferation (Mall et al, Bas ResCardiol, 85:531-540 (1990)).

Normal metabolic processes in vascular cells are associated with thegeneration of reactive oxygen intermediates that must be neutralized tolimit oxidative damage and cellular dysfunction. In the setting ofcommon cardiovascular diseases or disorders or in the presence of commonrisk factors for atherothrombotic disease, reactive oxygen species (ROS)are generated in abundance, and their rate of synthesis and fluxtypically exceeds the capacity of endogenous antioxidant mechanisms.Hypercholesterolemia, hyperglycemia (Keaney et al, Circulation,99:189-191 (1999)), cigarette smoking, hyperhomocysteinemia,hypertension, and frank atherosclerosis are all accompanied by anincrease in plasma and tissue ROS generation. Superoxide anion, hydrogenperoxide, hydroxyl radical, peroxynitrite, and lipid peroxides allincrease in these settings. What remains unknown is whether or not theincrease in ROS in these disorder is a primary event, a secondaryconsequence of the underlying process, or both.

Endogenous antioxidants important for the neutralization (i.e.,reduction) of ROS can be categorized into two groups: small-moleculeantioxidants and antioxidant enzymes. The former group comprisesmolecules such as GSH, NADPH, α-tocopherol, vitamin C, and ubiquinol-10;while the latter group comprises the superoxide dismutases, catalase,and glutathione peroxidases. Deficiencies in several of these molecularspecies have been shown to lead to increased steady-state levels of ROSand vascular dysfunction, including increased platelet activation,arterial thrombosis (Freedman et al, J Clin Invest, 97:979-987 (1996);Freedman et al, Circulation, 98:1481-1486 (1998)), and reducedproduction of platelet-derived NO (Kenet et al, Arterio Thromb VascBiol, 19(8): 2017-2023 (1999)), which is important for limitingexpansion of a platelet thrombus (Freedman et al, Circ Res, 84:1416-142(1999)).

ROS generation accompanies the vascular dysfunction associated withseveral models of atherothrombotic and hypertensive vascular diseases.Hyperhomo-cysteinemic mice (i.e., cystathionine β-synthase knock-outmice) (Eberhardt et al, Circulation, 98:144 (1998)), cellularglutathione peroxidase-deficient mice (i.e., cellular glutathioneperoxidase knock-out mice), and salt-induced hypertensive rats (i.e.,salt-fed Dahl S rats) (Trolliet et al, Circulation, 98:1-725 (1998)) allmanifest increased vascular ROS, and this increase in ROS is accompaniedby reduced NO bioactivity through oxidative inactivation. Endothelialfunction and NO availability can be improved by improving antioxidantstatus with a cysteine precursor (Vita et al, J Clin Invest,101:1408-1414 (1998)). In addition, α-tocopherol leads to plateletinhibition (Freedman et al, Circulation, 94:2434-2440 (1996)) as onemechanism of its atherothrombotic benefit (Stephens et al, Lancet,347:781-786 (1996)). Salt-loading salt-sensitive individuals (Dahl Srats) lead to an approximate 5-fold increase in plasma F₂-isoprostanes(8-epi-prostaglandin F₂), and this increase precedes the development offlorid hypertension. These data all support the role of oxidant stressin the genesis or evolution of vascular dysfunction and disease, and theimportance of antioxidant mechanisms in preventing this pathobiology,particularly with regard to African Americans.

In support of the mechanisms illustrated above, minimum forearm vascularresistance is significantly higher among normotensive blacks than whites(Bassett et al, Am J Hypertension, 5:781-786 (1992)), and forearmblood-flow responses to isoproterenol are markedly attenuated innormotensive blacks, suggesting a blunted β₂-vasodilator response inthese individuals (Lang et al, N EngI J Med, 333:155-160 (1995)). Blackstend to have greater left ventricular mass than whites for any givenlevel of blood pressure (Koren et al, Am J Hypertension, 6:815-823(1993); Chaturvedi et al, J Am Coll Cardiol, 24:1499-1505 (1994)). Whilenot quantitated in any necropsy study, this response is likely to beaccompanied by inadequate capillary angiogenesis, which, in turn, mayaccount for the diastolic dysfunction and the microvascular ischemiaobserved in blacks. Interestingly, blacks have been observed to have lowlevels of urinary kallikrein (Zinner et al, Am J Epidemiol, 104:124-132(1976); Levy et al, J Clin Invest, 60:129-138 (1977)), the enzymeresponsible for the generation of bradykinin from high-molecular-weightkininogen. Thus, were a similar abnormality in bradykinin andbradykinin-mediated NO production to exist in the coronary vasculature,attenuated blood flow responses may result that would limit capillaryangiogenic responses and prevent the endothelial proliferative effectsof locally derived NO.

As discovered and described herein, African Americans have a uniquevascular diathesis that may serve as the basis for clinically importantcardiovascular syndromes. For example, differences in the outcome ofleft ventricular dysfunction may be a consequence of the enhanced(perhaps salt-dependent) increase in oxidant stress coupled withmicrovascular endothelial dysfunction and an inadequately vascularized,hypertrophied left ventricle. This constellation of pathophysiologicalabnormalities may provide the substrate for the important differences inoutcome between blacks and whites with left ventricular dysfunction(Dreis et al, N EngI J Med, 340:609-616 (1999)). In addition, theseobservations and their clinical consequences suggest that blacks withabnormal endothelial function and nitric oxide insufficiency stateswould derive direct and, perhaps, disproportionate clinical benefit fromenhancing nitric oxide in the vasculature, either by improvingendothelial function, providing exogenous nitric oxide donors, or both.

The invention is directed to the treatment and/or prevention of vasculardiseases characterized by nitric oxide insufficiency; and for treatingand/or preventing Raynaud's syndrome and for treating and/or preventingcardiovascular diseases or disorders by administering nebivolol that isoptionally substituted with at least one NO and/or NO₂ group, and/or atleast one metabolite of nebivolol, that is optionally substituted withat least one NO and/or NO₂ group (i.e., nitrosylated and/or nitrosated).Preferably, the nitrosated and/or nitrosylated nebivolol, and/or itsnitrosylated and/or nitrosated metabolites are administered as apharmaceutical composition that further comprises a pharmaceuticallyacceptable carrier or diluent. The novel compounds and novelcompositions of the invention are described in more detail herein.

Nebivolol((±)-(RSSS)-αα′-(iminobis(methylene)bis-(6-fluoro-3,4-dihydro-2H-1-benzopyran-2-methanol)is a long lasting cardioselective 13-blocker having mild vasodilatingproperties. It is administered as its hydrochloride salt as mixture ofequal amounts of its 2 enantiomers (SRRR and RSSS) under the tradenamesNEBILET®, NEBILOX® or LOBIVON®. The structure of nebivolol with its fourstereogenic centers indicated with an asterisk is shown below:

The absorption of nebivolol is rapid and it is extensively metabolized,partly to active metabolites. Compounds contemplated for use in theinvention include nebivolol and all its metabolites known in the art andinclude those described herein, such as, for example, the hydroxyderivatives of nebivolol, the N-alkylated metabolites of nebivolol, andthe like. Nebivolol and its metabolites are disclosed in, for example,U.S. Pat. Nos. 4,654,362, 5,759,580, 6,075,046, and in EP 0 145 067, EP0 334 429, and in WO 95/22325 and WO 96/19987; Van Lommen et al., J.Pharm. Belg., 45(6): 355-360 (1990); Chandrasekhar, S. et al.,Tetrahedron, 56(34): 6339-6344 (2000); and Fendrickx et at., J.Chromatogr. A., 729: 341-354 (1996); the disclosures of each of whichare incorporated by reference herein in their entirety.

In one embodiment, the invention describes nitrosated and/ornitrosylated nebivolol of Formula (I), isomers thereof, andpharmaceutically acceptable salts thereof;

wherein:

D is hydrogen, Q, K or R₅;

D₁ is hydrogen or R₅;

R₅ is:

D₂ is hydrogen, Q or K;

Q is —NO or —NO₂;

K is—W_(a)-E_(b)-(C(R_(e))(R_(f)))_(p)-E_(c)-(C(R_(e))(R_(f)))_(x)—W_(d)—(C(R_(e))(R_(f)))_(y)—W_(i)-E_(j)-W_(g)—(C(R_(e))(R_(f)))_(z)-T-Q;

a, b, c, d, g, i and j are each independently an integer from 0 to 3;

p, x, y and z are each independently an integer from 0 to 10;

W at each occurrence is independently —C(O)—, —C(S)—, -T-,—(C(R_(e))(R_(f)))_(h)—, an alkyl group, an aryl group, a heterocyclicring, an arylheterocyclic ring, or —(CH₂CH₂O)_(q)—;

E at each occurrence is independently -T-, an alkyl group, an arylgroup, —(C(R_(e))(R_(f)))_(h)—, a heterocyclic ring, an arylheterocyclicring, or —(CH₂CH₂O)_(q)—;

h is an integer form 1 to 10;

q is an integer from 1 to 5;

R_(e) and R_(f) are each independently a hydrogen, an alkyl, acycloalkoxy, a halogen, a hydroxy, an hydroxyalkyl, an alkoxyalkyl, anarylheterocyclic ring, an alkylaryl, an alkylcycloalkyl, analkylheterocyclic ring, a cycloalkylalkyl, a cycloalkylthio, acycloalkenyl, an heterocyclicalkyl, an alkoxy, a haloalkoxy, an amino,an alkylamino, a dialkylamino, an arylamino, a diarylamino, analkylarylamino, an alkoxyhaloalkyl, a haloalkoxy, a sulfonic acid, asulfonic ester, an alkylsulfonic acid, an arylsulfonic acid, anarylalkoxy, an alkylthio, an arylthio, a cyano an aminoalkyl, anaminoaryl, an aryl, an arylalkyl, an alkylaryl, a carboxamido, aalkylcarboxamido, an arylcarboxamido, an amidyl, a carboxyl, acarbamoyl, an alkylcarboxylic acid, an arylcarboxylic acid, analkylcarbonyl, an arylcarbonyl, an ester, a carboxylic ester, analkylcarboxylic ester, an arylcarboxylic ester, a haloalkoxy, asulfonamido, an alkylsulfonamido, an arylsulfonamido, an alkylsulfonyl,an alkylsulfonyloxy, an arylsulfonyl, arylsulphonyloxy, a sulfonicester, a urea, a phosphoryl, a nitro, W_(h), -T-Q , or—(C(R_(e))(R_(f)))_(k)-T-Q, or R_(e) and R_(f) taken together with thecarbons to which they are attached form a carbonyl, a methanthial, aheterocyclic ring, a cycloalkyl group, an aryl group, an oxime or abridged cycloalkyl group;

k is an integer from 1 to 3;

T at each occurrence is independently a covalent bond, a carbonyl, anoxygen, —S(O)_(o)— or —N(R_(a))R_(i)—;

o is an integer from 0 to 2;

R_(a) is a lone pair of electrons, a hydrogen or an alkyl group;

R_(i) is a hydrogen, an alkyl, an aryl, an alkylcarboxylic acid, anarylcarboxylic acid, an alkylcarboxylic ester, an arylcarboxylic ester,an alkylcarboxamido, an arylcarboxamido, an alkylaryl, an alkylsulfinyl,an alkylsulfonyl, an alkylsulfonyloxy, an arylsulfinyl, an arylsulfonyl,arylsulphonyloxy, a sulfonamido, a carboxamido, a carboxylic ester, anaminoalkyl, an aminoaryl, —CH₂—C(T-Q)(R_(e))(R_(f)), a bond to anadjacent atom creating a double bond to that atom, —(N₂O₂—)⁻•M⁺, whereinM⁺ is an organic or inorganic cation;

with the proviso that the compound of Formula (I) must contain at leastone nitrite, nitrate, thionitrite or thionitrate group.

In cases where R_(e) and R_(f) are a heterocyclic ring or R_(e) andR_(f) taken together with the hetero atom to which they are attached area heterocyclic ring, then R_(i) can be a substituent on anydisubstituted nitrogen contained within the radical where R_(i) is asdefined herein.

In cases where multiple designations of variables that reside insequence are chosen as a “covalent bond” or the integer chosen is 0, theintent is to denote a single covalent bond connecting one radical toanother. For example, E₀ would denote a covalent bond, while E₂ denotes(E-E) and (C(R_(e))(R_(f)))₂ denotes —C(R_(e))(R_(f))—C(R_(e))(R_(f))—,where R_(e) and R_(f) at each occurrence are each independently selectedfrom those moieties defined herein.

Another embodiment of the invention describes the nitrosated and/ornitrosylated metabolites of nebivolol of Formula (II), Formula (III),Formula (IV) or Formula (V), isomers thereof, and pharmaceuticallyacceptable salts thereof;

wherein the compounds of Formula (II), Formula (III), Formula (IV) andFormula (V) are:

wherein:

R₆ at each occurrence is independently a hydrogen, a hydroxy or —OD;

D and D₁ are as defined herein; and with the proviso that the compoundsof Formula (II), Formula (III), Formula (IV) and Formula (V), mustcontain at least one nitrite, nitrate, thionitrite or thionitrate group.

Compounds of the invention, that have one or more asymmetric carbonatoms, can exist as the optically pure enantiomers, pure diastereomers,mixtures of enantiomers, mixtures of diastereomers, racemic mixtures ofenantiomers, diastereomeric racemates or mixtures of diastereomericracemates. It is to be understood that the invention anticipates andincludes within its scope all such isomers and mixtures thereof.

The parent nebivolol compound and its metabolites can be synthesized byone skilled in the art following the methods described in, for example,U.S. Pat. Nos. 4,654,362, 5,759,580, 6,075,046, and in EP 0 145 067, EP0 334 429, and in WO 95/22325 and WO 96/19987; Van Lommen et al., J.Pharm. Belg., 45(6): 355-360 (1990); Chandrasekhar, S. et al.,Tetrahedron, 56(34): 6339-6344 (2000); and Fendrickx et at., J.Chromatogr. A., 729: 341-354 (1996); the disclosure of each of which areincorporated by reference herein in their entirety. The parent nebivololcompound and its metabolites can be nitrosated and/or nitrosylatedthrough one or more sites such as oxygen (hydroxyl condensation), sulfur(sulfhydryl condensation), and/or nitrogen. The nitrosated andnitrosylated compounds of the invention can be prepared usingconventional methods known to one skilled in the art. For example, knownmethods for nitrosylating compounds are described in U.S. Pat. Nos.5,380,758 and 5,703,073; WO 97/27749; WO 98/19672; and Oae et al, Org.Prep. Proc. Int., 15(3):165-198 (1983), the disclosures of each of whichare incorporated by reference herein in their entirety.

Compounds of the invention can be synthesized following the methodsdescribed herein. The reactions are performed in solvents appropriate tothe reagents, and materials used are suitable for the transformationsbeing effected. It is understood by one skilled in the art of organicsynthesis that the functionality present in the molecule must beconsistent with the chemical transformation proposed. This will, onoccasion, necessitate judgment by the routineer as to the order ofsynthetic steps, protecting groups required, and deprotectionconditions. Substituents on the starting materials may be incompatiblewith some of the reaction conditions required in some of the methodsdescribed, but alternative methods and substituents compatible with thereaction conditions will be readily apparent to one skilled in the art.The use of sulfur and oxygen protecting groups is known in the art forprotecting thiol and alcohol groups against undesirable reactions duringa synthetic procedure and many such protecting groups are known, e.g.,T. H. Greene and P. G. M. Wuts, Protective Groups in Organic Synthesis,John Wiley & Sons, New York (1999), which is incorporated herein in itsentirety.

Compounds of the invention can be synthesized as shown in FIGS. 1 to 16.Nitroso compounds of Formula (I) wherein R_(e), R_(f), and p are definedas herein, D¹ is hydrogen, P^(1′) is an acetyl or trifluoroacetyl ester,and hydrogen and an O-nitrosylated ester are representative of the Dgroups as defined herein, may be prepared as outlined in FIG. 1. Theamine group of Formula 1 is protected to afford the compound of Formula2, wherein P³ is as defined herein. Preferred protecting groups for theamine are as a carbamate, such as, a benzyl or tert-butyl carbamate, oran amide, such as, a trifluoroacetamide. An alcohol group of Formula 2is converted to the ester of Formula 3, wherein p, R_(e) and R_(f) aredefined herein, by reaction with an appropriate protected alcoholcontaining activated acylating agent, wherein P¹ is as defined herein.Preferred methods for the formation of esters are reacting the alcoholwith the preformed acid chloride or symmetrical anhydride of theprotected alcohol containing acid or condensing the alcohol andprotected alcohol containing acid in the presence of a dehydratingagent, such as, dicyclohexylcarbodiimide (DCC) or1-ethyl-3-(3-dimethylaminopropyl)carbodiimide hydrochloride (EDAC.HCl)with or without a catalyst, such as, 4-dimethyaminopyridine (DMAP) or1-hydroxybenzotriazole (HOBt). Preferred protecting groups for thealcohol moiety are silyl ethers, such as, a trimethylsilyl or atert-butyldimethylsilyl ether. Protection of the remaining secondaryalcohol as an ester, such as, an acetyl or trifluoroacetyl ester,followed by deprotection of the silylated hydroxyl moiety (fluoride ionis the preferred method for removing silyl ether protecting groups) andthen reaction with a suitable nitrosylating agent, such as, thionylchloride nitrite, thionyl dinitrite, or nitrosonium tetrafluoroborate,in a suitable anhydrous solvent, such as, dichloromethane, THF, DMF, oracetonitrile, with or without an amine base, such as, pyridine ortriethylamine, affords the compound of Formula 4. The compound ofFormula 4 is then converted to the compound of Formula IA bydeprotecting the amine and remaining hydroxyl group. Hydrogen in thepresence of a transition metal catalyst, such as, palladium or platinum,is a preferred method for removing benzyl ether and benzyl carbamateprotecting groups, strong anhydrous acids, such as, trifluoroacetic acidor hydrochloric acid in methanol, dioxane or ethyl acetate are preferredfor removing the t-butyl carbamate protecting group and mild base, suchas, aqueous sodium or potassium carbonate or ammonia in methanol, arethe preferred methods for removing trifluoroacetamide, trifluoroacetylester or acetyl ester protecting groups.

Nitroso compounds of Formula (I) wherein P³, R_(e), R_(f), and p are asdefined herein, D¹ is hydrogen, and a S-nitrosylated ester arerepresentative of the D groups as defined herein, may be prepared asoutlined in FIG. 2. The compound of Formula 2, wherein P³ is as definedherein, with the preferred protecting group for the amine being acarbamate, such as, a t-butyl carbamate, is converted to the ester ofFormula 5, wherein p, R_(e) and R_(f), are as defined herein, byreaction with an appropriate protected thiol containing activatedacylating agent, wherein P² is as defined herein. Preferred methods forthe formation of esters are reacting the alcohol with the preformed acidchloride or symmetrical anhydride of the protected thiol containing acidor condensing the alcohol and protected thiol containing acid in thepresence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Preferred protecting groupsfor the thiol moiety are as a thioester, such as, a thioacetate orthiobenzoate, as a disulfide, as a thiocarbamate, such as,N-methoxymethyl thiocarbamate, or as a thioether, such as, aparamethoxybenzyl thioether, a tetrahydropyranyl thioether or a2,4,6-trimethoxybenzyl thioether. Deprotection of the thiol moiety (zincin dilute aqueous acid, triphenylphosphine in water and sodiumborohydride are the preferred methods for reducing disulfide groups,while aqueous base is typically utilized to hydrolyze thioesters, andN-methoxymethyl thiocarbamates and mercuric trifluoroacetate, or silvernitrate are the preferred methods to remove a paramethoxybenzylthioether, a tetrahydropyranyl thioether or a 2,4,6-trimethoxybenzylthioether group) affords a compound of Formula 6. Reaction of thecompound of Formula 6 with an eqimolar equivalent, based upon thiol, ofa suitable nitrosylating agent, such as, thionyl chloride nitrite,thionyl dinitrite, a lower alkyl nitrite, such as, tert-butyl nitrite,or nitrosonium tetrafluoroborate in a suitable anhydrous solvent, suchas, methylene chloride, THF, DMF, or acetonitrile, with or without anamine base, such as, pyridine or triethylamine affords the compound ofFormula 7. Alternatively, treatment of compound 6 with a stoichiometricquantity of sodium nitrite in an acidic aqueous or alcoholic solutionaffords the compound of Formula 7. The compound of Formula 7 is thenconverted to the compound of Formula IB by deprotecting the amine(strong acid, such as, HCl in dioxane or trifluoroacetic acid is used toremove a t-butyl carbamate).

Nitro compounds of Formula (I), wherein R_(e), R_(f), k, and p are asdefined herein, D¹ is hydrogen and a O-nitrosated ester arerepresentative of the D groups as defined herein, may be prepared asoutlined in FIG. 3. The compound of Formula 2, wherein P³ is as definedherein, with the preferred protecting group for the amine being acarbamate, such as, a t-butyl carbamate, is converted to the ester ofFormula 8, wherein p, R_(e) and R_(f) are as defined herein, by reactionwith an appropriate nitrate containing activated acylating agent.Preferred methods for the formation of esters are reacting the alcoholwith the preformed acid chloride or symmetrical anhydride of the nitratecontaining acid or condensing the alcohol and nitrate containing acid inthe presence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Deprotection of the amine(strong acid, such as, HCl in dioxane or trifluoroacetic acid is used toremove a t-butyl carbamate) affords a compound of Formula IC.

2-Hydroxy-2-nitrosohydrazine compounds of Formula (I), wherein R_(e),R_(f), R_(i), and p are as defined herein, D¹ is hydrogen and hydrogenand a 2-hydroxy-2-nitrosohydrazine ester are representative of the Dgroups as defined herein, may be prepared as outlined in FIG. 4. Thecompound of Formula 2, wherein P³ is as defined herein, with thepreferred protecting group for the amine being an amide, such as, atrifluoroacetamide, is converted to the ester of Formula 9, wherein p,R_(e), R_(f) and R_(i) are as defined herein, by reaction with anappropriate protected amine containing activated acylating agent whereinP^(3′) is an amine protecting group. Preferred P^(3′) protecting groupsfor the amine are as a carbamate, such as, a benzyl or tert-butylcarbamate. Preferred methods for the formation of esters are reactingthe alcohol with the preformed acid chloride or symmetrical anhydride ofthe protected amine containing acid or condensing the alcohol andprotected amine containing acid in the presence of a dehydrating agent,such as, DCC or EDAC.HCl, with or without a catalyst, such as, DMAP orHOBt. Removal of the P^(3′) amine protecting group (hydrogen in thepresence of a transition metal catalyst, such as, palladium or platinum,is a preferred method for removing benzyl carbamate protecting groups,strong anhydrous acids, such as, trifluoroacetic acid or hydrochloricacid in methanol, dioxane or ethyl acetate are preferred for removingthe t-butyl carbamate protecting group) followed by treatment of theamine with nitric oxide (1-5 atmospheres) in a dry inert solvent, suchas, ether or tetrahydrofuran, affords the compound of Formula 10 whereinM⁺, is as defined herein. The compound of Formula 10 is then convertedto the compound of Formula ID by removing the remaining amine protectinggroup (mild base, such as, aqueous sodium or potassium carbonate orammonia in methanol are the preferred methods for removingtrifluoroacetamide protecting groups).

Nitroso compounds of Formula (II) wherein R_(e), R_(f), and p are asdefined herein, P^(1′) is an acetyl or trifluoroacetyl ester or a benzylether, and hydrogen and an O-nitrosylated ester are representative ofthe D groups as defined above may be prepared as outlined in FIG. 5. Analcohol group of Formula 11 is converted to the ester of Formula 12wherein p, R_(e) and R_(f) are as defined herein by reaction with anappropriate protected alcohol containing activated acylating agent,wherein P¹ is as defined herein. Preferred methods for the formation ofesters are reacting the alcohol with the preformed acid chloride orsymmetrical anhydride of the protected alcohol containing acid orcondensing the alcohol and protected alcohol containing acid in thepresence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Preferred protecting groupsfor the alcohol moiety are silyl ethers, such as, a trimethylsilyl ortert-butyldimethylsilyl ether. Protection of the remaining secondaryalcohol as an ester, such as, an acetyl or trifluoroacetyl ester,followed by deprotection of the silylated hydroxyl moiety (fluoride ionis the preferred method for removing silyl ether protecting groups) andthen reaction a suitable nitrosylating agent, such as, thionyl chloridenitrite, thionyl dinitrite, or nitrosonium tetrafluoroborate, in asuitable anhydrous solvent, such as, dichloromethane, THF, DMF, oracetonitrile, with or without an amine base, such as, pyridine ortriethylamine affords the compound of Formula 13. The compound ofFormula 13 is then converted to the compound of Formula IIA bydeprotecting the remaining hydroxyl group. Hydrogen in the presence of atransition metal catalyst, such as, palladium or platinum, is apreferred method for removing the benzyl ether protecting group, andmild base, such as, aqueous sodium or potassium carbonate or ammonia inmethanol, are the preferred methods for removing, trifluoroacetyl esteror acetyl ester protecting groups.

Nitroso compounds of Formula (II) wherein R_(e), R_(f), and p are asdefined herein, and hydrogen and a S-nitrosylated ester arerepresentative of the D groups as defined herein, may be prepared asoutlined in FIG. 6. The compound of Formula 11 is converted to the esterof Formula 14, wherein p, R_(e) and R_(f), are as defined herein, byreaction with an appropriate protected thiol containing activatedacylating agent, wherein P² is as defined herein. Preferred methods forthe formation of esters are reacting the alcohol with the preformed acidchloride or symmetrical anhydride of the protected thiol containing acidor condensing the alcohol and protected thiol containing acid in thepresence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Preferred protecting groupsfor the thiol moiety are as a thioester, such as, a thioacetate orthiobenzoate, as a disulfide, as a thiocarbamate, such as,N-methoxymethyl thiocarbamate, or as a thioether, such as, aparamethoxybenzyl thioether, a tetrahydropyranyl thioether or a2,4,6-trimethoxybenzyl thioether. Deprotection of the thiol moiety (zincin dilute aqueous acid, triphenylphosphine in water and sodiumborohydride are preferred methods for reducing disulfide groups. whileaqueous base is typically utilized to hydrolyze thioesters andN-methoxymethyl thiocarbamates and mercuric trifluoroacetate, silvernitrate, or strong acids, such as, trifluoroacetic or hydrochloric acidand heat are used to remove a paramethoxybenzyl thioether, atetrahydropyranyl thioether or a 2,4,6-trimethoxybenzyl thioether group)to afford a compound of Formula 15. Reaction of the compound of Formula15 with an equimolar equivalent (based upon thiol) of a suitablenitrosylating agent, such as, thionyl chloride nitrite, thionyldinitrite, or a lower alkyl nitrite, such as, tert-butyl nitrite, ornitrosonium tetrafluoroborate in a suitable anhydrous solvent, such as,methylene chloride, THF, DMF, or acetonitrile, with or without an aminebase, such as, pyridine or triethylamine, affords the compound ofFormula IIB. Alternatively, treatment of compound 15 with astoichiometric quantity of sodium nitrite in an acidic aqueous oralcoholic solution affords the compound of Formula IIB.

Nitro compounds of Formula (II), wherein R_(e), R_(f), k, and p are asdefined here, and hydrogen and an O-nitrosated ester are representativeof the D groups as defined herein, may be prepared as outlined in FIG.7. The compound of Formula 11 is converted to the ester of Formula IIC,wherein p, k, R_(e) and R_(f), are as defined herein, by reaction withan appropriate nitrate containing activated acylating agent. Preferredmethods for the formation of esters are reacting the alcohol with thepreformed acid chloride or symmetrical anhydride of the nitratecontaining acid or condensing the alcohol and nitrate containing acid inthe presence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt.

2-Hydroxy-2-nitrosohydrazine compounds of Formula (II), wherein R_(e).R_(f), R_(i), and p, are as defined herein, and hydrogen and a2-hydroxy-2-nitrosohydrazine ester are representative of the D groups,as defined herein, may be prepared as outlined in FIG. 8. The compoundof Formula 11 is converted to the ester of Formula 16, wherein p, R_(i),R_(e) and R_(f) are as defined herein, by reaction with an appropriateprotected amine containing activated acylating agent, wherein P³ is anamine protecting group. Preferred protecting groups for the amine are asa carbamate, such as, a benzyl or tert-butyl carbamate. Preferredmethods for the formation of esters are reacting the alcohol with thepreformed acid chloride or symmetrical anhydride of the protected aminecontaining acid or condensing the alcohol and protected amine containingacid in the presence of a dehydrating agent, such as, DCC or EDAC.HCl,with or without a catalyst, such as, DMAP or HOBt. Removal of the P³amine protecting group (hydrogen in the presence of a transition metalcatalyst, such as, palladium or platinum, is a preferred method forremoving benzyl carbamate protecting groups, while strong anhydrousacids, such as, trifluoroacetic acid or hydrochloric acid in methanol,dioxane or ethyl acetate, are preferred for removing the t-butylcarbamate protecting group) followed by treatment of the amine withnitric oxide (1-5 atmospheres) in a dry inert solvent, such as, ether ortetrahydrofuran, affords the compound of Formula IID, wherein M+is asdefined herein.

Nitroso compounds of Formula (III) wherein R_(e), R_(f), and p are asdefined herein, P^(1′) is an acetyl ester or a benzyl carbonate, andhydrogen and an O-nitrosylated ester are representative of the D groupsas defined herein, may be prepared as outlined in FIG. 9. The alcoholand acid groups of Formula 17 are protected to afford the compound ofFormula 18. Preferred protecting groups for the alcohol are as acarbamate, such as, a benzyl carbonate or an ester, such as, a acetylester, while preferred protecting groups for the acids are as an ester,such as, t-butyl ester. Deprotection of the hydroxyl moiety (catalytichydrogenation is the preferred method for cleaving benzyl carbonateswhile mild aqueous base removes the acetyl ester group) followed byreaction of the alcohol group with an appropriate protected alcoholcontaining activated acylating agent, wherein R_(e), R_(f), and p andP¹, are as defined herein, affords a compound of Formula 19. Preferredmethods for the formation of esters are reacting the alcohol with thepreformed acid chloride or symmetrical anhydride of the protectedalcohol containing acid or condensing the alcohol and protected alcoholcontaining acid in the presence of a dehydrating agent, such as, DCC orEDAC.HCl, with or without, a catalyst, such as, DMAP or HOBt. Preferredprotecting groups for the alcohol moiety are silyl ethers, such as, atert-butyldimethylsilyl ether. Deprotection of the acid and hydroxylmoieties (strong acid, such as, HCl in dioxane or trifluoroacetic acidcleaves t-butyl esters while fluoride ion is the preferred method forremoving silyl ether protecting groups) followed by reaction a suitablenitrosylating agent, such as, thionyl chloride nitrite, thionyldinitrite, or nitrosonium tetrafluoroborate in a suitable anhydroussolvent, such as, dichloromethane, THF, DMF, or acetonitrile with orwithout an amine base, such as, pyridine or triethylamine affords thecompound of Formula IIIA.

Nitroso compounds of Formula (III) wherein R_(e), R_(f), and p are asdefined herein, P^(1′) is an acetyl ester or a benzyl carbonate, andhydrogen and an O-nitrosylated ester are representative of the D groupsas defined herein, may be prepared as outlined in FIG. 10. The compoundof Formula 18, wherein the preferred protecting groups for the alcoholare as a carbonate, such as, a benzyl carbonate or an ester, such as, aacetyl ester, while a preferred protecting group for the acid is as anester, such as, t-butyl ester, is converted to the compound of Formula20 by removal of the t-butyl ester moiety (strong acid, such as, HCl indioxane or trifluoroacetic acid cleaves t-butyl esters). The compound ofFormula 20 is converted to the ester of Formula 21 by reaction of theacid group with an appropriate protected alcohol containing alcohol,wherein R_(e), R_(f), p and P¹ are as defined herein. Preferred methodsfor the formation of esters are reacting the alcohol with the preformedacid chloride or symmetrical anhydride of the protected alcoholcontaining acid or condensing the alcohol and protected alcoholcontaining acid in the presence of a dehydrating agent, such as, DCC orEDAC.HCl with or without a catalyst, such as, DMAP or HOBt. Preferredprotecting groups for the alcohol moiety on the protected alcoholcontaining alcohol are silyl ethers, such as, tert-butyldimethylsilylether. Deprotection of the silyl hydroxyl moiety (fluoride ion is thepreferred method for removing silyl ether protecting groups) followed byreaction a suitable nitrosylating agent, such as, thionyl chloridenitrite, thionyl dinitrite, or nitrosonium tetrafluoroborate in asuitable anhydrous solvent, such as, dichloromethane, THF, DMF, oracetonitrile, with or without an amine base, such as, pyridine ortriethylamine, affords the compound of Formula 22. Removal of theremaining hydroxylprotecting group (catalytic hydrogenation is thepreferred method for cleaving benzyl carbonates while mild aqueous baseremoves the acetyl ester group) affords the compound of Formula IIIB.

Nitroso compounds of Formula (III), wherein R_(e), R_(f), and p are asdefined herein, and hydrogen and an S-nitrosylated ester arerepresentative of the D group as defined herein, may be prepared asoutlined in FIG. 11. The compound of Formula 18, wherein the preferredprotecting groups for the alcohol are as a carbonate, such as, a benzylcarbonate or an ester, such as, a acetyl ester while preferredprotecting groups for the acid is as an ester, such as, a t-butyl ester,is converted to the compound of Formula 23 by deprotection of thehydroxyl moiety (catalytic hydrogenation is the preferred method forcleaving benzyl carbonates while mild aqueous base removes the acetylester group). Reaction of the alcohol group with an appropriateprotected thiol containing activated acylating agent, wherein R_(e),R_(f), and p and P², are as defined herein, afford the compound ofFormula 24. Preferred methods for the formation of esters are reactingthe alcohol with the preformed acid chloride or symmetrical anhydride ofthe protected thiol containing acid or condensing the alcohol andprotected thiol containing acid in the presence of a dehydrating agent,such as, DCC or EDAC.HCl, with or without a catalyst, such as, DMAP orHOBt. Preferred protecting groups for the thiol moiety are as athioester, such as, a thioacetate or thiobenzoate, as a disulfide, as athiocarbamate, such as, N-methoxymethyl thiocarbamate, or as athioether, such as, a paramethoxybenzyl thioether, a tetrahydropyranylthioether or a 2,4,6-trimethoxybenzyl thioether. Deprotection of thethiol and acid moieties (zinc in dilute aqueous acid, triphenylphosphinein water and sodium borohydride are preferred methods for reducingdisulfide groups, while aqueous base is typically utilized to hydrolyzethioesters and N-methoxymethyl thiocarbamates and mercurictrifluoroacetate, silver nitrate, or strong acids, such as,trifluoroacetic or hydrochloric acid and heat, are used to remove aparamethoxybenzyl thioether, a tetrahydropyranyl thioether, or a2,4,6-trimethoxybenzyl thioether group as well as t-butyl esters)followed by reaction a suitable nitrosylating agent, such a,s thionylchloride nitrite, thionyl dinitrite, a lower alkyl nitrite, such as,tert-butyl nitrite, or nitrosonium tetrafluoroborate in a suitableanhydrous solvent, such as, methylene chloride, THF, DMF, oracetonitrile, with or without an amine base, such as, pyridine ortriethylamine, affords the compound of Formula IIIC. Alternatively,treatment of the deprotected compound with a stoichiometric quantity ofsodium nitrite in an acidic aqueous or alcoholic solution affords thecompound of Formula IIIC.

Nitroso compounds of Formula (III) wherein R_(e), R_(f), and p are asdefined herein, P^(1′) is an acetyl ester or a silyl ether, such as,trimethylsilyl ether or t-butyldimethylsilyl ether, and hydrogen and anS-nitrosylated ester are representative of the D groups as definedherein, may be prepared as outlined in FIG. 12. The compound of Formula20 is converted to the ester of Formula 25 by reaction of the acid groupwith an appropriate protected thiol containing alcohol wherein R_(e),R_(f), and p and P², are as defined herein. Preferred methods for theformation of esters are reacting the alcohol with the preformed acidchloride or symmetrical anhydride of the protected alcohol containingacid or condensing the alcohol and protected alcohol containing acid inthe presence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Preferred protecting groupsfor the thiol moiety are as a thioester, such as, a thioacetate orthiobenzoate, as a disulfide, as a thiocarbamate such as,N-methoxymethyl thiocarbamate, or as a thioether, such as, aparamethoxybenzyl thioether, a tetrahydropyranyl thioether or a2,4,6-trimethoxybenzyl thioether. Deprotection of the thiol and alcoholmoieties (zinc in dilute aqueous acid, triphenylphosphine in water andsodium borohydride are preferred methods for reducing disulfide groupswhile aqueous base is typically utilized to hydrolyze thioesters, estersand N-methoxymethyl thiocarbamates and mercuric trifluoroacetate, silvernitrate, or strong acids, such as, trifluoroacetic or hydrochloric acidand heat, are used to remove a paramethoxybenzyl thioether, atetrahydropyranyl thioether, or a 2,4,6-trimethoxybenzyl thioethergroup, while fluoride is the preferred method for removing silyl etherprotecting groups) followed by reaction a suitable nitrosylating agent,such as, thionyl chloride nitrite, thionyl dinitrite, a lower alkylnitrite, such as, tert-butyl nitrite, or nitrosonium tetrafluoroborate,in a suitable anhydrous solvent, such as, methylene chloride, THF, DMF,or acetonitrile, with or without an amine base, such as, pyridine ortriethylamine, affords the compound of Formula IIID. Alternatively,treatment of the deprotected compound with a stoichiometric quantity ofsodium nitrite in an acidic aqueous or alcoholic solution affords thecompound of Formula IIID.

Nitro compounds of Formula (III), wherein R_(e), R_(f), k, and p are asdefined herein, and hydrogen and an O-nitrosated ester arerepresentative of the D groups as defined herein, may be prepared asoutlined in FIG. 13. The compound of Formula 23 is converted to theester of Formula 26 wherein p, k, R_(e) and R_(f) are as defined herein,by reaction with an appropriate nitrate containing activated acylatingagent. Preferred methods for the formation of esters are reacting thealcohol with the preformed acid chloride or symmetrical anhydride of thenitrate containing acid or condensing the alcohol and nitrate containingacid in the presence of a dehydrating agent, such as, DCC or EDAC.HCl,with or without a catalyst, such as, DMAP or HOBt. Deprotection of theacid (strong acid, such as, HCl in dioxane or trifluoroacetic acidcleaves t-butyl esters) affords the compound of Formula IIIE.

Nitro compounds of Formula (III) wherein R_(e), R_(f), and p are asdefined herein, and hydrogen and an O-nitrosated ester arerepresentative of the D groups as defined herein, may be prepared asoutlined in FIG. 14. The compound of Formula 20, wherein the preferredalcohol protecting group is an ester, such as, an acetyl ester or asilyl ether, such as, a trimethylsilyl of tert-butyldimethyl silyl etheris converted to the ester of Formula 27 wherein p, R_(e) and R_(f) aredefined as herein, by reaction with an appropriate nitrate containingalcohol. Preferred methods for the formation of esters are reacting thenitrate containing alcohol with the preformed acid chloride orsymmetrical anhydride or condensing the nitrate containing alcohol andacid in the presence of a dehydrating agent, such as, DCC or EDAC.HCl,with or without a catalyst, such as, DMAP or HOBt. Removal of theremaining hydroxylprotecting group (mild aqueous base removes the acetylester group while fluoride ion is the preferred method for removingsilyl ether protecting groups) affords the compound of Formula IIIF.

2-Hydroxy-2-nitrosohydrazine compounds of Formula (III) wherein R_(e),R_(f), R_(i), and p are as defined herein, and hydrogen and a2-hydroxy-2-nitrosohydrazine ester are representative of the D groups asdefined herein, may be prepared as outlined in FIG. 15. The alcoholgroup of Formula 25 is converted to the ester of Formula 28 wherein p,R_(e), R_(f), R¹ and P³ are as defined herein, by reaction with anappropriate protected amine containing activated acylating agent.Preferred methods for the formation of esters are reacting the alcoholwith the preformed acid chloride or symmetrical anhydride of theprotected amino containing acid or condensing the alcohol and protectedamine containing acid in the presence of a dehydrating agent, such as,DCC or EDAC.HCl, with or without a catalyst, such as, DMAP or HOBt.Preferred protecting groups for the amine are as a carbamate, such as, at-butyl carbamate or a 9-fluorenylmethyl carbamate or an amide, such as,a trifluoroacetamide. Deprotection of the amino and t-butyl estermoieties (strong acid, such as, HCl in dioxane or trifluoroacetic acid,is used to remove a t-butyl carbamate as well as the t-butyl estergroups, while piperidine is used to remove 9-fluorenylmethyl carbamate,and mild aqueous or alcoholic base may be used to cleave atrifluoroacetamide group) followed by treatment of the amine with nitricoxide (1-5 atmospheres) in a dry inert solvent, such as, ether ortetrahydrofuran, affords the compound of Formula IIIG wherein M⁺ is asdefined herein.

2-Hydroxy-2-nitrosohydrazine compounds of Formula (III) wherein R_(e),R_(f), R_(i), and p are as defined herein. P¹ is preferably an acetylester or silyl protecting group, such as, trimethylsilyl ether ort-butyldimethylsilyl ether, and hydrogen and a2-hydroxy-2-nitrosohydrazine ester are representative of the D groups asdefined herein, may be prepared as outlined in FIG. 16. The acid groupof Formula 20 is converted to the ester of Formula 29 wherein p, R_(e),R_(f), R_(i) and P³ are as defined herein, by reaction with anappropriate protected amine containing alcohol. Preferred methods forthe formation of esters are reacting the protected amine containingalcohol with the preformed acid chloride or symmetrical anhydride of theacid or condensing the protected amine containing alcohol and acid inthe presence of a dehydrating agent, such as, DCC or EDAC.HCl, with orwithout a catalyst, such as, DMAP or HOBt. Preferred protecting groupsfor the amine are as a carbamate, such as, a t-butyl carbamate or a9-fluorenylmethyl carbamate or an amide, such as, a trifluoroacetamide.Deprotection of the amino and alcohol moieties (strong acid, such as,HCl in dioxane or trifluoroacetic acid, is used to remove a t-butylcarbamat, while piperidine is used to remove 9-fluorenylmethylcarbamate, while mild aqueous or alcoholic base may be used to cleave aacetyl ester group, and fluoride is used for removing silyl ethers)followed by treatment of the amine with nitric oxide (1-5 atmospheres)in a dry inert solvent, such as, ether or tetrahydrofuran affords thecompound of Formula IIIH, wherein M⁺ is as defined herein.

The nitrosated and/or nitrosylated nebivolol and the nitrosated and/ornitrosylated metabolites of nebivolol of the invention donate, transferor release a biologically active form of nitrogen monoxide (nitricoxide). Nitrogen monoxide can exist in three forms: NO− (nitroxyl), NO•(nitric oxide) and NO⁺ (nitrosonium). NO— is a highly reactiveshort-lived species that is potentially toxic to cells. This is criticalbecause the pharmacological efficacy of NO depends upon the form inwhich it is delivered. In contrast to the nitric oxide radical (NO•),nitrosonium (NO⁺) does not react with O₂ or O₂— species, andfunctionalities capable of transferring and/or releasing NO⁺ and NO− arealso resistant to decomposition in the presence of many redox metals.Consequently, administration of charged NO equivalents (positive and/ornegative) does not result in the generation of toxic by-products or theelimination of the active NO moiety.

Compounds contemplated for use in the invention (e.g., nebivolol and/ornitrosated and/or nitrosylated nebivolol and/or metabolites of nebivololand/or metabolites of nitrosated and/or nitrosylated nebivolol) are,optionally, used in combination with nitric oxide and compounds thatrelease nitric oxide or otherwise directly or indirectly deliver ortransfer nitric oxide to a site of its activity, such as on a cellmembrane in vivo.

The term “nitric oxide” encompasses uncharged nitric oxide (NO•) andcharged nitrogen monoxide species, preferably charged nitrogen monoxidespecies, such as nitrosonium ion (NO⁺) and nitroxyl ion (NO−). Thereactive form of nitric oxide can be provided by gaseous nitric oxide.The nitrogen monoxide releasing, delivering or transferring compoundshave the structure F—NO, wherein F is a nitrogen monoxide releasing,delivering or transferring moiety, and include any and all suchcompounds which provide nitrogen monoxide to its intended site of actionin a form active for its intended purpose. The term “NO adducts”encompasses any nitrogen monoxide releasing, delivering or transferringcompounds, including, for example, S-nitrosothiols, nitrites, nitrates,S-nitrothiols, sydnonimines, 2-hydroxy-2-nitrosohydrazines, (NONOates),(E)-alkyl-2-((E)-hydroxyimino)-5-nitro-3-hexeneamide (FK-409),(E)-alkyl-2-((E)-hydroxyimino)-5-nitro-3-hexeneamines,N-((2Z,3E)-4-ethyl-2-(hydroxyimino)-6-methyl-5-nitro-3-heptenyl)-3-pyridinecarboxamide(FR 146801), nitrosoamines, furoxans as well as substrates for theendogenous enzymes which synthesize nitric oxide. NONOates include, butare not limited to,(Z)-1-(N-methyl-N-(6-(N-methyl-ammoniohexyl)amino))diazen-1-ium-1,2-diolate(“MAHMA/NO”),(Z)-1-(N-(3-ammoniopropyl)-N-(n-propyl)amino)diazen-1-ium-1,2-diolate(“PAPA/NO”), (Z)-1-(N-(3-aminopropyl)-N-(4-(3-aminopropylammonio)butyl)-amino)diazen-1-ium-1,2-diolate (spermine NONOate or “SPER/NO”)and sodium (Z)-1-(N,N-diethylamino) diazenium-1,2-diolate (diethylamineNONOate or “DEA/NO”) and derivatives thereof. NONOates are alsodescribed in U.S. Pat. Nos. 6,232,336, 5,910,316 and 5,650,447, thedisclosures of which are incorporated herein by reference in theirentirety. The “NO adducts” can be mono-nitrosylated, poly-nitrosylated,mono-nitrosated and/or poly-nitrosated at a variety of naturallysusceptible or artificially provided binding sites for biologicallyactive forms of nitrogen monoxide.

One group of NO adducts is the S-nitrosothiols, which are compounds thatinclude at least one —S—NO group. These compounds includeS-nitroso-polypeptides (the term “polypeptide” includes proteins andpolyamino acids that do not possess an ascertained biological function,and derivatives thereof); S-nitrosylated amino acids (including naturaland synthetic amino acids and their stereoisomers and racemic mixturesand derivatives thereof); S-nitrosylated sugars; S-nitrosylated,modified and unmodified, oligonucleotides (preferably of at least 5, andmore preferably 5-200 nucleotides); straight or branched, saturated orunsaturated, aliphatic or aromatic, substituted or unsubstitutedS-nitrosylated hydrocarbons; and S-nitroso heterocyclic compounds.S-nitrosothiols and methods for preparing them are described in U.S.Pat. Nos. 5,380,758 and 5,703,073; WO 97/27749; WO 98/19672; and Oae etal, Org. Prep. Proc. Int., 15(3):165-198 (1983), the disclosures of eachof which are incorporated by reference herein in their entirety.

Another embodiment of the invention is S-nitroso amino acids where thenitroso group is linked to a sulfur group of a sulfur-containing aminoacid or derivative thereof. Such compounds include, for example,S-nitroso-N-acetylcysteine, S-nitroso-captopril,S-nitroso-N-acetylpenicillamine, S-nitroso-homocysteine,S-nitroso-cysteine, S-nitroso-glutathione, S-nitroso-cysteinyl-glycine,and the like.

Suitable S-nitrosylated proteins include thiol-containing proteins(where the NO group is attached to one or more sulfur groups on an aminoacid or amino acid derivative thereof) from various functional classesincluding enzymes, such as tissue-type plasminogen activator (TPA) andcathepsin B; transport proteins, such as lipoproteins; heme proteins,such as hemoglobin and serum albumin; and biologically protectiveproteins, such as immunoglobulins, antibodies and cytokines. Suchnitrosylated proteins are described in WO 93/09806, the disclosure ofwhich is incorporated by reference herein in its entirety. Examplesinclude polynitrosylated albumin where one or more thiol or othernucleophilic centers in the protein are modified.

Other examples of suitable S-nitrosothiols include:

(i) HS(C(R_(e))(R_(f)))_(m)SNO;

(ii) ONS(C(R_(e))(R_(f)))_(m)R_(e); and

(iii) H₂N—CH(CO₂H)—(CH₂)_(m)—C(O)NH—CH(CH₂SNO)—C(O)NH—CH₂—CO₂H;

wherein m is an integer from 2 to 20; R_(e) and R_(f) are eachindependently a hydrogen, an alkyl, a cycloalkoxy, a halogen, a hydroxy,an hydroxyalkyl, an alkoxyalkyl, an arylheterocyclic ring, an alkylaryl,an alkylcycloalkyl, an alkylheterocyclic ring, a cycloalkylalkyl, acycloalkylthio, a cycloalkenyl, an heterocyclicalkyl, an alkoxy, ahaloalkoxy, an amino, an alkylamino, a dialkylamino, an arylamino, adiarylamino, an alkylarylamino, an alkoxyhaloalkyl, a haloalkoxy, asulfonic acid, a sulfonic ester, an alkylsulfonic acid, an arylsulfonicacid, an arylalkoxy, an alkylthio, an arylthio, a cyano an aminoalkyl,an aminoaryl, an aryl, an arylalkyl, an alkylaryl, a carboxamido, aalkylcarboxamido, an arylcarboxamido, an amidyl, a carboxyl, acarbamoyl, an alkylcarboxylic acid, an arylcarboxylic acid, analkylcarbonyl, an arylcarbonyl, an ester, a carboxylic ester, analkylcarboxylic ester, an arylcarboxylic ester, a haloalkoxy, asulfonamido, an alkylsulfonamido, an arylsulfonamido, an alkylsulfonyl,an alkylsulfonyloxy, an arylsulfonyl, arylsulphonyloxy, a sulfonicester, a urea, a phosphoryl, a nitro, W_(h), -T-Q, or—(C(R_(e))(R_(f)))_(k)-T-Q, or R_(e) and R_(f) taken together with thecarbons to which they are attached form a carbonyl, a methanthial, aheterocyclic ring, a cycloalkyl group, an aryl group, an oxime or abridged cycloalkyl group; Q is —NO or —NO₂; and T is independently acovalent bond, a carbonyl, an oxygen, —S(O)_(o)— or —N(R_(a))R_(i)—,wherein o is an integer from 0 to 2, R_(a) is a lone pair of electrons,a hydrogen or an alkyl group; R_(i) is a hydrogen, an alkyl, an aryl, analkylcarboxylic acid, an arylcarboxylic acid, an alkylcarboxylic ester,an arylcarboxylic ester, an alkylcarboxamido, an arylcarboxamido, analkylaryl, an alkylsulfinyl, an alkylsulfonyl, an alkylsulfonyloxy, anarylsulfinyl, an arylsulfonyl, arylsulphonyloxy, a sulfonamido, acarboxamido, a carboxylic ester, an aminoalkyl, an aminoaryl,—CH₂—C(T-Q)(R_(e))(R_(f)), a bond to an adjacent atom creating a doublebond to that atom, —(N₂O₂—)⁻•M⁺, wherein M⁺ is an organic or inorganiccation; with the proviso that when R_(i) is —CH₂—C(T-Q)(R_(e))(R_(f)) or—(N₂O₂—)•M⁺; then “-T-Q” can be a hydrogen, an alkyl group, analkoxyalkyl group, an aminoalkyl group, a hydroxy group or an arylgroup.

In cases where R_(e) and R_(f) are a heterocyclic ring or R_(e) andR_(f) taken together with the hetero atom to which they are attached area heterocyclic ring, then R_(i) can be a substituent on anydisubstituted nitrogen contained within the radical wherein R_(i) is asdefined herein.

Nitrosothiols can be prepared by various methods of synthesis. Ingeneral, the thiol precursor is prepared first, then converted to theS-nitrosothiol derivative by nitrosation of the thiol group with NaNO₂under acidic conditions (pH is about 2.5) which yields the S-nitrosoderivative. Acids which can be used for this purpose include aqueoussulfuric, acetic and hydrochloric acids. The thiol precursor can also benitrosylated by reaction with an organic nitrite such as tert-butylnitrite, or a nitrosonium salt such as nitrosonium tetrafluoroborate inan inert solvent.

Another group of NO adducts for use in the invention, where the NOadduct is a compound that donates, transfers or releases nitric oxide,include compounds comprising at least one ON—O—, ON—N— or ON—C— group.The compounds that include at least one ON—O—, ON—N— or ON—C— group arepreferably ON—O—, ON—N— or ON—C-polypeptides (the term “polypeptide”includes proteins and polyamino acids that do not possess an ascertainedbiological function, and derivatives thereof); ON—O—, ON—N— orON—C-amino acids (including natural and synthetic amino acids and theirstereoisomers and racemic mixtures); ON—O—, ON—N— or ON—C-sugars; ON—O—,ON—N— or ON—C— modified or unmodified oligonucleotides (comprising atleast 5 nucleotides, preferably 5-200 nucleotides); ON—O—, ON—N— orON—C-straight or branched, saturated or unsaturated, aliphatic oraromatic, substituted or unsubstituted hydrocarbons; and ON—O—, ON—N— orON—C-heterocyclic compounds.

Another group of NO adducts for use in the invention include nitratesthat donate, transfer or release nitric oxide, such as compoundscomprising at least one O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C— group.Preferred among these compounds are O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C—polypeptides (the term “polypeptide” includes proteins and alsopolyamino acids that do not possess an ascertained biological function,and derivatives thereof); O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C— amino acids(including natural and synthetic amino acids and their stereoisomers andracemic mixtures); O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C-sugars; O₂N—O—,O₂N—N—, O₂N—S— or O₂N—C— modified and unmodified oligonucleotides(comprising at least 5 nucleotides, preferably 5-200 nucleotides);O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C— straight or branched, saturated orunsaturated, aliphatic or aromatic, substituted or unsubstitutedhydrocarbons; and O₂N—O—, O₂N—N—, O₂N—S— or O₂N—C— heterocycliccompounds. Preferred examples of compounds comprising at least oneO₂N—O—, O₂N—N—, O₂N—S— or O₂N—C— group include isosorbide dinitrate,isosorbide mononitrate, clonitrate, erythrityl tetranitrate, mannitolhexanitrate, nitroglycerin, pentaerythritoltetranitrate, pentrinitrol,propatylnitrate and organic nitrates with a sulfhydryl-containing aminoacid such as, for example SPM 3672, SPM 5185, SPM 5186 and thosedisclosed in U.S. Pat. Nos. 5,284,872, 5,428,061, 5,661,129, 5,807,847and 5,883,122 and in U.S. Provisional Application No. 60/311,175 and inWO 97/46521 and WO 00/54756, the disclosures of each of which areincorporated by reference herein in their entirety.

Another group of NO adducts are N-oxo-N-nitrosoamines that donate,transfer or release nitric oxide and are represented by the Formula:R¹R²N—N(O-M+)—NO, where R¹ and R² are each independently a polypeptide,an amino acid, a sugar, a modified or unmodified oligonucleotide, astraight or branched, saturated or unsaturated, aliphatic or aromatic,substituted or unsubstituted hydrocarbon, or a heterocyclic group, andwhere M⁺ is an organic or inorganic cation, such as, for example, analkyl substituted ammonium cation or a Group I metal cation.

Another group of NO adducts are thionitrates that donate, transfer orrelease nitric oxide and are represented by the formula: R¹—(S)—NO₂,where R¹ is a polypeptide, an amino acid, a sugar, a modified orunmodified oligonucleotide, a straight or branched, saturated orunsaturated, aliphatic or aromatic, substituted or unsubstitutedhydrocarbon, or a heterocyclic group. Preferred are those compoundswhere R¹ is a polypeptide or hydrocarbon with a pair or pairs of thiolsthat are sufficiently structurally proximate, i.e., vicinal, that thepair of thiols will be reduced to a disulfide. Compounds which formdisulfide species release nitroxyl ion (NO−) and uncharged nitric oxide(NO•).

The invention is also directed to compounds that stimulate endogenous NOor elevate levels of endogenous endothelium-derived relaxing factor(EDRF) in vivo or are substrates for the enzyme, nitric oxide synthase.Such compounds include, for example, L-arginine, L-homoarginine, andN-hydroxy-L-arginine, including their nitrosated and nitrosylatedanalogs (e.g., nitrosated L-arginine, nitrosylated L-arginine,nitrosated N-hydroxy-L-arginine, nitrosylated N-hydroxy-L-arginine,nitrosated L-homoarginine and nitrosylated L-homoarginine), precursorsof L-arginine and/or physiologically acceptable salts thereof,including, for example, citrulline, ornithine, glutamine, lysine,polypeptides comprising at least one of these amino acids, inhibitors ofthe enzyme arginase (e.g., N-hydroxy-L-arginine and2(S)-amino-6-boronohexanoic acid) and the substrates for nitric oxidesynthase, cytokines, adenosin, bradykinin, calreticulin, bisacodyl, andphenolphthalein. EDRF is a vascular relaxing factor secreted by theendothelium, and has been identified as nitric oxide (NO) or a closelyrelated derivative thereof (Palmer et al, Nature, 327:524-526 (1987);Ignarro et al, Proc. Natl. Acad. Sci. USA, 84:9265-9269 (1987)).

The invention is also based on the discovery that the administration ofa therapeutically effective amount of the compounds and compositionsdescribed herein is effective for treating and/or preventing vasculardiseases characterized by nitric oxide (NO) insufficiency. For example,the patient can be administered a therapeutically effective amount of atleast one nitrosated and/or nitrosylated nebivolol of the invention. Inanother embodiment, the patient can be administered a therapeuticallyeffective amount of at least one nitrosated and/or nitrosylatedmetabolite of nebivolol. In yet another embodiment, the patient can beadministered a therapeutically effective amount of nebivolol, optionallysubstituted with at least one NO and/or NO₂ group, and/or at least onemetabolite of nebivolol, optionally substituted with at least one NOand/or NO₂ group, and at least one compound that donates, transfers orreleases nitric oxide as a charged species, or elevates levels ofendogenous EDRF or nitric oxide, or is a substrate for nitric oxidesynthase. In another embodiment, the patient can be administered atherapeutically effective amount of nebivolol, optionally substitutedwith at least one NO and/or NO₂ group, and/or at least one metabolite ofnebivolol, optionally substituted with at least one NO and/or NO₂ group,and, optionally, at least one compound that donates, transfers orreleases nitric oxide as a charged species, or elevates levels ofendogenous EDRF or nitric oxide, or is a substrate for nitric oxidesynthase and/or at least one antioxidant or a pharmaceuticallyacceptable salt thereof, and/or at least one compound used to treatcardiovascular diseases, or a pharmaceutically acceptable salt thereof.The compound used to treat cardiovascular diseases can optionally besubstituted with at least one NO₂ group (i.e. nitrosated). The compoundscan be administered separately or as a composition.

In the invention the compound that donates, transfers or releases nitricoxide as a charged species, or elevates levels of endogenous EDRF ornitric oxide, or is a substrate for nitric oxide synthase may preferablybe isosorbide dinitrate and/or isosorbide mononitrate, more preferablyisosorbide dinitrate. Diluted isosorbidedinitrate(1,4,3,6-dianhydro-D-glucitol-2,5-dinitrate), USP, is a whiteto off-white powder that has a melting point of 70° C. and has anoptical rotation of +135° (3 mg/mL, ethanol). It is freely soluble inorganic solvents such as ethanol, ether and chloroform, but is sparinglysoluble in water. Isosorbide dinitrate is commercially available, forexample, under the trade names DILATRATE®-SR (Schwarz Pharma, Milwaukee,Wis.); ISORDIL® and ISORDILR TITRADOSE® (Wyeth Laboratories Inc.,Philadelphia, Pa.); and SORBITRATE® (Zeneca Pharmaceuticals, Wilmington,Del.). Isosorbide mononitrate is commercially available, for example,under the trade names IMDUR® (A. B. Astra, Sweden); MONOKET® (SchwarzPharma, Milwaukee, Wis.); and ISMO® (Wyeth-Ayerst company, Philadelphia,Pa.).

In the invention, the antioxidants include small-molecule antioxidantsand antioxidant enzymes. Antioxidant refers to and includes any compoundthat can react and quench a free radical. Suitable small-moleculeantioxidants include, but are not limited to, hydralazine compounds,glutathione, vitamin C, vitamin E, cysteine, N-acetyl-cysteine,β-carotene, ubiquinone, ubiquinol-10, tocopherols, coenzyme Q, and thelike. Suitable antioxidant enzymes include, but are not limited to,superoxide dismutase, catalase, glutathione peroxidase, and the like.Suitable antioxidants are described more fully in the literature, suchas in Goodman and Gilman, The Pharmacological Basis of Therapeutics (9thEdition), McGraw-Hill, 1995; and the Merck Index on CD-ROM, TwelfthEdition, Version 12:1, 1996; and on STN Express, file phar and file reg.The preferred antioxidant is a hydralazine compound that may preferablybe administered as a pharmaceutically acceptable salt; more preferablyas hydralazine hydrochloride. Hydralazine hydrochloride is commerciallyavailable from, for example, Lederle Standard Products (Pearl River,N.Y.), and Par Pharmaceuticals Inc. (Spring Valley, N.Y.).

The compound used to treat cardiovascular diseases, or apharmaceutically acceptable salt, include, but are not limited to,angiotensin-converting enzyme (ACE) inhibitors, beta-adrenergicblockers, cholesterol reducers, calcium channel blockers, angiotensin IIreceptor antagonists, endothelin antagonists, renin inhibitors, and thelike, and mixtures thereof.

Suitable angiotensin-converting enzyme inhibitors, include, but are notlimited to, alacepril, benazepril, captopril, ceronapril, cilazapril,delapril, duinapril, enalapril, enalaprilat, fosinopril, imidapril,lisinopril, losartan, moveltipril, naphthopidil, pentopril, perindopril,quinapril, ramipril, rentipril, spirapril, temocapril, trandolapril,urapidil, zofenopril, and the like. Suitable angiotensin-convertingenzyme inhibitors are described more fully in the literature, such as inGoodman and Gilman, The Pharmacological Basis of Therapeutics (9thEdition), McGraw-Hill, 1995; and the Merck Index on CD-ROM, TwelfthEdition, Version 12:1, 1996; and on STN Express, file phar and fileregistry.

Suitable beta-adrenergic blockers, include, but are not limited to,acebutolol, alprenolol, amosulalol, arotinolol, atenolol, betaxolol,bethanidine, bevantolol, bisoprolol, bopindolol, bucumolol, bufetolol,bufuralol, bunitrolol, bupranolol, butafilolol, carazolol, carteolol,carvedilol, celiprolol, cetamolol, dilevalol, epanolol, esmolol,indenolol, labetalol, mepindolol, metipranolol, metoprolol, moprolol,nadolol, nadoxolol, nifenalol, nipradilol, oxprenolol, penbutolol,pindolol, practolol, pronethalol, propranolol, sotalol, sulfinalol,talinolol, tertatolol, tilisolol, timolol, toliprolol, xibenolol, andthe like. Suitable beta-adrenergic blockers are described more fully inthe literature, such as in Goodman and Gilman, The Pharmacological Basisof Therapeutics (9th Edition), McGraw-Hill, 1995; and the Merck Index onCD-ROM, Twelfth Edition, Version 12:1, 1996; and on STN Express, filephar and file registry.

Suitable cholesterol reducers include but are not limited to HMG-CoAreductase inhibitors, such as, for example, lovastatin (MEVACOR®),simvastatin (ZOCOR®), pravastatin (PRAVACHOL®), fluvastatin,cerivastatin (BAYCOL®), atorvastatin (LIPITOR®), and the like;sequestrants such as, for example, cholestyramine, colestipol,sialkylaminoalkyl derivatives of cross-linked dextran, and the like;inhibitors of cholesterol absorption, such as, for example,beta-sitosterol, acyl CoA-cholersterol acyltransferase inhibitors,melinamide, and the like. Suitable calcium channel blockers aredescribed more fully in the literature, such as in Goodman and Gilman,The Pharmacological Basis of Therapeutics (9th Edition), McGraw-Hill,1995; and the Merck Index on CD-ROM, Twelfth Edition, Version 12:1,1996; and on STN Express, file phar and file registry.

Suitable calcium channel blockers, include, but are not limited to,amlodipine, aranidipine, barnidipine, benidipine, cilnidipine,clentiazem, diltiazen, efonidipine, fantofarone, felodipine, isradipine,lacidipine, lercanidipine, manidipine, mibefradil, nicardipine,nifedipine, nilvadipine, nisoldipine, nitrendipine, semotiadil,veraparmil, and the like. Suitable calcium channel blockers aredescribed more fully in the literature, such as in Goodman and Gilman,The Pharmacological Basis of Therapeutics (9th Edition), McGraw-Hill,1995; and the Merck Index on CD-ROM, Twelfth Edition, Version 12:1,1996; and on STN Express, file phar and file registry.

Suitable endothelin antagonists, include, but are not limited to,bosentan, sulfonamide endothelin antagonists, BQ-123, SQ 28608, and thelike. Suitable endothelin antagonists are described more fully in theliterature, such as in Goodman and Gilman, The Pharmacological Basis ofTherapeutics (9th Edition), McGraw-Hill, 1995; and the Merck Index onCD-ROM, Twelfth Edition, Version 12:1, 1996; and on STN Express, filephar and file registry.

Suitable angiotensin II receptor antagonists, include, but are notlimited to, ciclosidomine, eprosartan, furosemide, irbesartan, losartan,saralasin, valsartan, and the like. Suitable angiotensin II receptorantagonists are described more fully in the literature, such as inGoodman and Gilman, The Pharmacological Basis of Therapeutics (9thEdition), McGraw-Hill, 1995; and the Merck Index on CD-ROM, TwelfthEdition, Version 12:1, 1996; and on STN Express, file phar and fileregistry.

Suitable renin inhibitors, include, but are not limited to, enalkrein,RO 42-5892, A 65317, CP 80794, ES 1005, ES 8891, SQ 34017, and thelike). Suitable renin inhibitors are described more fully in theliterature, such as in Goodman and Gilman, The Pharmacological Basis ofTherapeutics (9th Edition), McGraw-Hill, 1995; and the Merck Index onCD-ROM, Twelfth Edition, Version 12:1, 1996; and on STN Express, filephar and file registry.

The compound used to treat cardiovascular diseases, or apharmaceutically acceptable salt, can be nitrosated through one or moresites such as oxygen (hydroxyl condensation), sulfur (sulfhydrylcondensation), and/or nitrogen. The nitrosated angiotensin-convertingenzyme inhibitors, nitrosated beta-adrenergic blockers, nitrosatedcholesterol reducer, nitrosated calcium channel blockers, nitrosatedendothelin antagonists, nitrosated angiotensin II receptor antagonistsand nitrosated renin inhibitors of the invention include any knownangiotensin-converting enzyme inhibitors, beta-adrenergic blockers,cholesterol reducer, calcium channel blockers, endothelin antagonists,angiotensin II receptor antagonists and renin inhibitors that have beennitrosated through one or more sites such as oxygen (hydroxylcondensation), sulfur (sulfhydryl condensation), and/or nitrogen. Thenitrosated compounds of the invention can be prepared using conventionalmethods known to one skilled in the art. For example, known methods fornitrosating compounds are described in U.S. Pat. Nos. 5,380,758 and5,703,073; WO 97/27749; WO 98/19672; and Oae et al, Org. Prep. Proc.Int., 15(3):165-198 (1983), the disclosures of each of which areincorporated by reference herein in their entirety. WO 98/21193discloses nitrosated ACE inhibitors and nitrosated beta-adrenergicblockers, the disclosure of which is incorporated by reference herein inits entirety. WO 99/00361 discloses nitrate salts of ACE inhibitors, thedisclosure of which is incorporated by reference herein in its entirety.

In addition to the administration of the combination of nebivolol,optionally substituted with at least one NO and/or NO₂ group, and/or atleast one metabolite of nebivolol, optionally substituted with at leastone NO and/or NO₂ group, and at least one compound that donates,transfers or releases nitric oxide as a charged species, or elevateslevels of endogenous EDRF or nitric oxide, or is a substrate for nitricoxide synthase and the antioxidant and/or the compound used to treatcardiovascular diseases, for the treatment of vascular diseasescharacterized by nitric oxide insufficiency, the patients can receivedigitalis such as digoxin and/or diuretics.

The digoxin may preferably be administered orally to achieve a steadystate blood serum concentration of at least about 0.7 nanograms per mlto about 2.0 nanograms per ml. The diuretic is administered, preferablyorally, to manage edema. Suitable diuretics include, but are not limitedto, thiazides (such as, for example, chlorothiazide,hydrochlorothiazide); ethacrynic acid, furosemide, spironalactone,triamterene or mixtures thereof. Depending on the diuretic used,potassium may also be administered to the patient in order to optimizethe fluid balance while avoiding hypokalemic alkalosis. Theadministration of potassium can be as potassium chloride or by the dailyingestion of foods with high potassium content such as, for example,bananas, orange juice, and the like. The method of administration ofthese compounds is described in further detail in U.S. Pat. No.4,868,179, the disclosure of which is incorporated by reference hereinin its entirety.

The invention also provides methods of preventing and treating Raynaud'ssyndrome by administering a therapeutically effective amount of at leastone nebivolol, optionally substituted with at least one NO and/or NO₂group, and/or at least one metabolite of nebivolol, optionallysubstituted with at least one NO and/or NO₂ group, and, optionally, atleast one compound that donates, transfers or releases nitric oxide as acharged species, or elevates levels of endogenous EDRF or nitric oxide,or is a substrate for nitric oxide synthase and/or at least oneantioxidant or a pharmaceutically acceptable salt thereof, and/or atleast one nitrosated compound used to treat cardiovascular diseases suchas, for example, nitrosated angiotensin-converting enzyme inhibitor,nitrosated beta-adrenergic blocker, nitrosated cholesterol reducer,nitrosated calcium channel blocker, nitrosated endothelin antagonist,nitrosated angiotensin II receptor antagonist and/or nitrosated renininhibitor. For example, the patient can be administered atherapeutically effective amount of at least one nitrosated and/ornitrosylated nebivolol of the invention. In another embodiment, thepatient can be administered a therapeutically effective amount of atleast one nitrosated and/or nitrosylated metabolite of nebivolol. In yetanother embodiment, the patient can be administered a therapeuticallyeffective amount of nebivolol, optionally substituted with at least oneNO and/or NO₂ group, and/or at least one metabolite of nebivolol,optionally substituted with at least one NO and/or NO₂ group, and atleast one compound that donates, transfers or releases nitric oxide as acharged species, or elevates levels of endogenous EDRF or nitric oxide,or is a substrate for nitric oxide synthase. In another embodiment, thepatient can be administered a therapeutically effective amount ofnebivolol, optionally substituted with at least one NO and/or NO₂ group,and/or at least one metabolite of nebivolol, optionally substituted withat least one NO and/or NO₂ group, and, optionally, at least one compoundthat donates, transfers or releases nitric oxide as a charged species,or elevates levels of endogenous EDRF or nitric oxide, or is a substratefor nitric oxide synthase and/or at least one antioxidant or apharmaceutically acceptable salt thereof, and/or at least one nitrosatedcompound used to treat cardiovascular diseases. For example, the patientcan be administered a nitrosated and/or nitrosylated nebivolol, a nitricoxide donor and an antioxidant, or the patient can be administered anitrosated and/or nitrosylated metabolite of nebivolol, a nitric oxidedonor and an antioxidant, or the patient can be administered nebivolol,a nitric oxide donor and an antioxidant. The nebivolol, nitric oxidedonor, antioxidant and nitrosated compound used to treat cardiovasculardiseases can be administered separately or as components of the samecomposition. Raynaud's syndrome is a condition that causes a loss ofblood flow to the fingers, toes, nose and/or ears. The affected areaturns white from the lack of circulation, then blue and cold, andfinally numb. The affected area may also turn red, and may throb, tingleor swell.

In the methods of the invention nebivolol, optionally substituted withat least one NO and/or NO₂ group, the metabolites of nebivolol,optionally substituted with at least one NO and/or NO₂ group, and,optionally, nitric oxide donor, antioxidant and/or compound used totreat cardiovascular diseases, optionally substituted with at least oneNO₂ group, can be administered as separate components or as componentsof the same composition. When the nebivolol, optionally substituted withat least one NO and/or NO₂ group, metabolite of nebivolol, optionallysubstituted with at least one NO and/or NO₂ group, and, optionally,nitric oxide donor, antioxidant, and/or compound used to treatcardiovascular diseases, optionally substituted with at least one NO₂group, are administered as separate components for the treatment ofvascular diseases characterized by nitric oxide insufficiency orRaynaud's syndrome, they are preferably administered to the patient atabout the same time. “About the same time” includes after administeringone compound (e.g., nebivolol or metabolite of nebivolol or nitric oxidedonor or antioxidant or compound used to treat cardiovascular diseases)to the patient, the other compound (e.g., nitric oxide donor orantioxidant or compound used to treat cardiovascular diseases ornebivolol or metabolite of nebivolol) is administered to the patient.“About the same time” also includes simultaneous administration of thecompounds or administering the compounds at the same time, at differenttimes on the same day, or on different days, as long as they areadministered as part of an overall treatment regimen.

Another embodiment of the invention provides compositions comprisingnebivolol, optionally substituted with at least one NO and/or NO₂ group,and/or at least one metabolite of nebivolol, that are optionallynitrosated and/or nitrosylated, and, optionally, at least one compoundthat donates, transfers or releases nitric oxide and/or stimulates theendogenous production of NO or EDRF in vivo and/or is a substrate fornitric oxide synthase and/or at least one therapeutic agent and/or atleast one nitrosated and/or nitrosylated therapeutic agent, bound to amatrix.

The nitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol and, optionally, NO donors and/ortherapeutic agent and/or nitrosated and/or nitrosylated therapeuticagent, can be incorporated into a natural or synthetic matrix which canthen be applied with specificity to a biological site of interest.Accordingly the optionally substituted nebivolol and/or metabolite ofnebivolol, and, optionally, NO donor is “bound to the matrix” whichmeans that the nitrosated and/or nitrosylated nebivolol and/ornitrosated and/or nitrosylated metabolite of nebivolol, and, optionally,NO donors and/or therapeutic agent and/or nitrosated and/or nitrosylatedtherapeutic agent, are physically and/or chemically associated with partof, incorporated with, attached to, or contained within the natural orsynthetic matrix. In one embodiment, physical association or bonding canbe achieved, for example, by coprecipitation of the nitrosated and/ornitrosylated nebivolol and/or nitrosated and/or nitrosylated metaboliteof nebivolol, and, optionally, NO donor and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, with the matrix. Inanother embodiment, chemical association or bonding can be achieved by,for example, covalent bonding of a nucleophilic moiety of the nitrosatedand/or nitrosylated nebivolol and/or nitrosated and/or nitrosylatedmetabolite of nebivolol, and, optionally, NO donor and/or therapeuticagent and/or nitrosated and/or nitrosylated therapeutic agent, to thematrix, such that nebivolol and/or metabolite of nebivolol is part ofthe matrix itself. In yet another embodiment, the nitrosated and/ornitrosylated nebivolol and/or nitrosated and/or nitrosylated metaboliteof nebivolol, and, optionally, NO donor and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, can be incorporatedinto a porous layer of the matrix or into pores included in the naturalor synthetic matrix. The manner in which the nitrosated and/ornitrosylated nebivolol and/or nitrosated and/or nitrosylated metaboliteof nebivolol, and, optionally, NO donor and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, is associated, partof, attached to, incorporated with or contained within (i.e. “bound to”)the matrix is inconsequential to the invention and all means ofassociation, incorporation, attachment, and bonding are contemplatedherein. Incorporation of the nitrosated and/or nitrosylated nebivololand/or nitrosated and/or nitrosylated metabolite of nebivolol, and,optionally, NO donors and/or therapeutic agent and/or nitrosated and/ornitrosylated therapeutic agent, into the matrix results in site-specificapplication, thereby enhancing selectivity of action for the releasednitric oxide and nebivolol and/or metabolite of nebivolol. Additionally,incorporation of the nitrosated and/or nitrosylated nebivolol and/ornitrosated and/or nitrosylated metabolite of nebivolol into the matrixreduces the rate of release of the nitric oxide and nebivolol and/ormetabolite of nebivolol. This prolongs the release of the nitric oxideand nebivolol and/or metabolite of nebivolol thereby allowing forefficient dosing to achieve a desired biological effect so that thefrequency of dosing can be reduced.

Any of a wide variety of natural or synthetic polymers can be used asthe matrix in the context of the invention. It is only necessary for thematrix to be biologically acceptable. Exemplary matrixes suitable foruse in the invention are polymers including, for example, polyolefins(such as polystyrene, polypropylene, polyethylene, high densitypolyethylene, polytetrafluorethylene, polyvinylidene diflouride andpolyvinylchloride), polyethylenimine or derivatives thereof, polyethers(such as polyethylene glycol), polyesters (such as poly-L-lactic acid,poly-D, L-lactic, poly-D-lactic, polyglycolic,poly-(lactide/glycolide)), polyanhydrides, polyhydroxybutyrates,polyamides (such as nylon), polyurethanes, polyurethane copolymers (suchas pellethane polymers), polyacrylates (such as polymethacrylate, poly(2-(methacryloyloxyethyl)-2′-(trimethylammonium)ethyl phosphate innersalt-co-n-dodecyl methacrylate), mixtures of polymers (such aspolylactic acid/polylysine copolymers, polyurethane/polyestercopolymers, polyurethane/polyether copolymers, nylon/polyethercopolymers, such as vestamid), biopolymers (such as peptides, proteins,oligonucleotides, antibodies, peptide hormones, glycoproteins, glycogenand nucleic acids), starburst dendrimers, natural fibrous matrix (suchas filter paper), synthetic fibrous matrix materials (such asthree-dimensional lattice of synthetic polymers and copolymers) and thelike. Exemplary polymers are described in U.S. Pat. Nos. 5,705,583,5,770,645 and 5,994,444 and application Ser. No. 08/460,465, thedisclosures of which are incorporated by reference herein in theirentirety.

The physical and structural characteristics of the matrixes suitable foruse in the invention are not critical, but depend on the application. Itwill be appreciated by one skilled in the art that where thematrix-nebivolol and/or matrix-metabolite of nebivolol composition ofthe invention is intended for local, relatively short termadministration or similar administration they need not be biodegradable.For some uses, such as postangioplasty, coronary bypass surgery orintimal hyperplasia associated with vascular graft implants or the like,it may be desirable for the matrix to slowly dissolve in a physiologicalenvironment or to be biodegradable or bioresorbable.

The nitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol and/or nebivolol and, optionally,the compound that donates, transfers or releases nitric oxide and/orstimulates the endogenous production of NO or EDRF in vivo and/or is asubstrate for nitric oxide synthase and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, bound to the matrixmay be administered in a wide variety of forms or delivery means. Anydelivery means should adequately protect the integrity of the nitricoxide prior to its release and should control the release of the nitricoxide at such a rate, in such an amount, and in such a location as toserve as an effective means for prevention and/or treatment ofcardiovascular diseases or disorders, including restenosis. Deliverymeans for local administration include, for example, sutures, vascularimplants, stents, heart valves, drug pumps, drug delivery catheters andthe like. Delivery means for systemic administration include, forexample, solutions, suspensions, emulsions, capsules, powders, sachets,tablets, effervescent tablets, topical patches, lozenges, aerosols,liposomes, microparticles, microspheres, beads and the like. The matrixitself may be structurally sufficient to serve as a delivery means.

The nitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol and/or nebivolol and, optionally,the compound that donates, transfers or releases nitric oxide and/orstimulates the endogenous production of NO or EDRF in vivo and/or is asubstrate for nitric oxide synthase, and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, bound to the matrixcan also be used to coat the surface of a medical device or instrumentthat comes into contact with blood (including blood components and bloodproducts) or vascular tissue thereby rendering the surface passive.Alternatively the nitrosated and/or nitrosylated nebivolol and/ornitrosated and/or nitrosylated metabolite of nebivolol and/or nebivololand the compound that donates, transfers or releases nitric oxide and/orstimulates the endogenous production of NO or EDRF in vivo and/or is asubstrate for nitric oxide synthase, and/or therapeutic agent and/ornitrosated and/or nitrosylated therapeutic agent, bound to the matrixcan also be used to coat the surface of a medical device or instrumentthat comes into contact with blood (including blood components and bloodproducts) or vascular tissue thereby rendering the surface passive. U.S.Pat. Nos. 5,837,008, 5,665,077, 5,797,887 and 5,824,049, the disclosuresof each of which are incorporated by reference herein in their entirety,describe methods for coating a surface of a medical device orinstrument. Thus, for example, (i) all or a portion of the medicaldevice may be coated with the nitrosated and/or nitrosylated nebivolol,and, optionally, NO donors and/or therapeutic agents and/or nitrosatedand/or nitrosylated therapeutic agents, either as the coating per se orbound to a matrix, as described herein; or (ii) all or a portion of themedical device may be produced from a material which includes thenitrosated and/or nitrosylated nebivolol, and, optionally, NO donor,therapeutic agent and nitrosated and/or nitrosylated therapeutic agent,per se or bound to a matrix, as described herein.

It is also contemplated that artificial surfaces will vary depending onthe nature of the surface, and such characteristics including contour,crystallinity, hydrophobicity, hydrophilicity, capacity for hydrogenbonding, and flexibility of the molecular backbone and polymers.Therefore, using routine methods, one of ordinary skill will be able tocustomize the coating technique by adjusting such parameters as theamount of adduct, length of treatment, temperature, diluents, andstorage conditions, in order to provide optimal coating of eachparticular type of surface.

After the device or artificial material has been coated with thenitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol, and, optionally, NO donor, and/ortherapeutic agent and/or nitrosated and/or nitrosylated therapeuticagent, or with nebivolol and/or metabolite of nebivolol and NO donor,and, optionally, therapeutic agent and/or nitrosated and/or nitrosylatedtherapeutic agent, it will be suitable for its intended use, including,for example, implantation as a heart valve, insertion as a catheter,insertion as a stent, or for cardiopulmonary oxygenation orhemodialysis.

Therapeutic agents useful in the invention include, but is not limitedto, agents which biologically stent a vessel and/or reduce or inhibitvascular remodeling and/or inhibit or reduce vascular smooth muscleproliferation following a procedural vascular trauma. The “therapeuticagents” of the invention include agents that inhibit the cellularactivity of a vascular smooth muscle cell, for example, proliferation,migration, increase in cell volume, increase in extracellular matrixsynthesis (e.g., collagens, proteoglycans, and the like), or secretionof extracellular matrix materials by the cell. Suitable “therapeuticagents” include, but are not limited to, antithrombogenic agents (suchas, for example, heparin, covalent heparin, hirudin, hirulog, coumadin,protamine, argatroban, D-phenylalanyl-L-poly-L-arginyl chloromethylketone, and the like); thrombolytic agents (such as, for example,urokinase, streptokinase, tissueplasminogen activators, and the like);fibrinolytic agents; vasospasm inhibitors; potassium channel activators(such as, for example, nicorandil, pinacidil, cromakalim, minoxidil,aprilkalim, loprazolam and the like); calcium channel blockers (such as,for example, nifedipine, veraparmil, diltiazem, gallopamil, niludipine,nimodipins, nicardipine, and the like); antihypertensive agents (suchas, for example, HYTRIN®, and the like); antimicrobial agents orantibiotics (such as, for example, adriamycin, and the like);antiplatelet agents (such as, for example, aspirin, ticlopidine, aglycoprotein IIb/IIa inhibitor, surface glycoprotein receptors and thelike); antimitotic, antiproliferative agents or microtubule inhibitors(such as, for example, taxanes, colchicine, methotrexate, azathioprine,vincristine, vinblastine, cytochalasin, fluorouracil, adriamycin,mutamycin, tubercidin, epothilone A or B, discodermolide, and the like);antisecretory agents (such as, for example, retinoid, and the like);remodelling inhibitors; antisense nucleotides (such as, for example,deoxyribonucleic acid, and the like); anti-cancer agents (such as, forexample, tamoxifen citrate, acivicin, bizelesin, daunorubicin,epirubicin, mitoxantrone, and the like); steroids (such as, for example,dexamethasone, dexamethasone sodium phosphate, dexamethasone acetate,and the like); non-steroidal antiinflammatory agents (NSAID); COX-2inhibitors; immunosuppressive agents (such as, for example cyclosporin,rapamycin, everolimus, actinomycin D and the like); growth factorantagonists or antibodies (such as, for example, trapidal (a PDGFantagonist), angiopeptin (a growth hormone antagonist), angiogenin, andthe like); dopamine agonists (such as, for example, apomorphine,bromocriptine, testosterone, cocaine, strychnine, and the like);radiotherapeutic agents (such as, for example, ⁶⁰Co (5.3 year halflife), ¹⁹²Ir (73.8 days), ³²P (14.3 days), ¹¹¹In (68 hours), ⁹⁰ Y (64hours), ^(99m)Tc (6 hours), and the like); heavy metals functioning asradiopaque agents (such as, for example, iodine-containing compounds,barium-containing compounds, gold, tantalum, platinum, tungsten, and thelike); biologic agents (such as, for example, peptides, proteins,enzymes, extracellular matrix components, cellular components, and thelike); angiotensin converting enzyme (ACE) inhibitors; angiotensin IIreceptor antagonists; renin inhibitiors; free radical scavengers, ironchelators or antioxidants (such as, for example, ascorbic acid, alphatocopherol, superoxide dismutase, deferoxamine, 21-aminosteroid, and thelike); sex hormones (such as, for example, estrogen, and the like);antipolymerases (such as, for example, AZT, and the like); antiviralagents (such as, for example, acyclovir, famciclovir, rimantadinehydrochloride, ganciclovir sodium, Norvir®, Crixivan®, and the like);photodynamic therapy agents (such as, for example, 5-aminolevulinicacid, meta-tetrahydroxyphenylchlorin, hexadecafluoro zincphthalocyanine, tetramethyl hematoporphyrin, rhodamine 123, and thelike); antibody targeted therapy agents (such as, for example, IgG2Kappa antibodies against Pseudomonas aeruginosa exotoxin A and reactivewith A431 epidermoid carcinoma cells, monoclonal antibody against thenoradrenergic enzyme dopamine beta-hydroxylase conjugated to saporin,and the like); and gene therapy agent. Preferred therapeutic agents,include antiproliferative agents, such as, for example, taxanes;steroids such as, for example, dexamethasone, immunosuppressive agents,such as for example, rapamycin, everolimus, actinomycin D and the like.The therapeutic agent can optionally be substituted with at least one NOand/or NO₂ group (i.e., nitrosylated and/or nitrosated) through one ormore sites such as oxygen (hydroxyl condensation), sulfur (sulfhydrylcondensation), and/or nitrogen. The compounds and compositions of theinvention can also be administered in combination with other medicationsused for the treatment of these diseases or disorders.

Suitable taxanes, include, but are not limited to, for example,paclitaxel and docetaxel, water soluble compositions of paclitaxel anddocetaxel, pro-drugs of paclitaxel and docetaxel, as well as functionalanalogs, equivalents or derivatives of taxanes, and the like. Forexample, derivatives and analogs of taxanes include, but are not limitedto, baccatin III, 10-deacetyltaxol, 7-xylosyl-10-deacetyltaxol,cephalomannine, 10-deacetyl-7-epitaxol, 7-epitaxol, 10-deacetylbaccatinIII, 10-deacetylcephaolmannine and analogs or derivatives, and the like.Taxanes are disclosed in, for example, U.S. Pat. Nos. 4,960,790,5,157,049, 5,284,864, 5,399,726, 5,550,261, 5,616,608, 5,629,433,5,646,176, 5,688,977, 5,703,117, 5,760,072, 5,808,113, 5,912,263,5,919,815, 5,965,739, 5,977,163, 5,981,564, 5,998,656, 6,017,935,6,017,948, 6,028,205 and in WO 93/17121, WO 94/15599, WO 95/20582, WO96/00724, WO 96/40091, WO 97/10234, WO 97/19938, WO 97/32578, WO97/33552, WO 98/00419, WO 98/28288, WO 98/37765, WO 98/38862, WO99/14209, WO 99/49901, WO 99/57105, WO 00/10988 and in EP 0 558 959 B1,EP 0 624 377 A2, EP 0 639 577 A1, the disclosures of each of which areincorporated by reference herein in their entirety. Taxanes and theirnitrosating and/or nitrosylated derivatives are also disclosed in U.S.application Ser. No. 09/886,494, assigned to NitroMed Inc.; and in WO00/61537, WO 00/61541 and WO 01/12584; the disclosure of each of whichare incorporated by reference herein in its entirety.

Suitable anticoagulants include, but are not limited to, heparin,coumarin, aspirin, protamine, warfarin, dicumarol, phenprocoumon,indan-1,3-dione, acenocoumarol, ansindione, and the like. Suitableanticoagulants are described more fully in the literature, such as inGoodman and Gilman, The Pharmacological Basis of Therapeutics (9thEdition), McGraw-Hill, 1995, Pgs. 1341-1359; the Merck Index on CD-ROM,Twelfth Edition, Version 12:1, 1996; STN express file reg and file phar.

Another embodiment of the invention provides methods for the preventionof platelet aggregation and platelet adhesion caused by the exposure ofblood (including blood components or blood products) to a medical deviceor instrument by incorporating at least one nitrosated and/ornitrosylated nebivolol and/or nitrosated and/or nitrosylated metaboliteof nebivolol and/or nebivolol, and, optionally, at least one compoundthat donates, transfers or releases nitric oxide and/or stimulates theendogenous production of NO or EDRF in vivo and/or is a substrate fornitric oxide synthase, and/or therapeutic agent and/or nitrosated and/ornitrosylated therapeutic agent, capable of releasing a therapeuticallyeffective amount of nitric oxide, into and/or on the portion(s) of themedical device that come into contact with blood (including bloodcomponents or blood products) or vascular tissue. The nitrosated and/ornitrosylated nebivolol and/or nitrosated and/or nitrosylated metaboliteof nebivolol and/or nebivolol, and, optionally, NO donors, therapeuticagents and/or nitrosated and/or nitrosylated therapeutic agents, may bedirectly or indirectly linked to the natural or synthetic polymericmaterial from which all or a portion of the device is made, as disclosedin U.S. Pat. Nos. 6,087,479 and 6,174,539, assigned to NitroMed, thedisclosure of each of which are incorporated by reference herein in itsentirety. Alternatively, the nitrosated and/or nitrosylated nebivolol,and/or nitrosated and/or nitrosylated metabolite of nebivolol and/ornebivolol, and, optionally, NO donors, therapeutic agents and/ornitrosated and/or nitrosylated therapeutic agents, may be incorporatedinto the body of the device that is formed of a biodegradable orbioresorbable material, including the matrix described herein. Thus thenitric oxide is released over a sustained period of the resorption ordegradation of the body of the device.

Another embodiment of the invention relates to local administration ofthe nitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol and/or nebivolol, and, optionally,at least one compound that donates, transfers or releases nitric oxideand/or stimulates the endogenous production of NO or EDRF in vivo and/oris a substrate for nitric oxide synthase, and/or at least onetherapeutic agent and/or at least one nitrosated and/or nitrosylatedtherapeutic agent, to the site of injured or damaged tissue (e.g.,damaged blood vessels) for the treatment of the injured or damagedtissue. Such damage may result from the use of a medical device in aninvasive procedure. Thus, for example, in treating blocked vasculatureby, for example, angioplasty, damage can result to the blood vessel.Such damage may be treated by use of the compounds and compositionsdescribed herein. In addition to repair of the damaged tissue, suchtreatment can also be used to prevent and/or alleviate and/or delayre-occlusions, for example, restenosis. The compounds and compositionscan be locally delivered using any of the methods known to one skilledin the art, including but not limited to, a drug delivery catheter, aninfusion catheter, a drug delivery guidewire, an implantable medicaldevice, and the like. In one embodiment, all or most of the damaged areais coated with the nitrosated and/or nitrosylated nebivolol describedherein per se or in a pharmaceutically acceptable carrier or excipientwhich serves as a coating matrix, including the matrix described herein.This coating matrix can be of a liquid, gel or semisolid consistency.The carrier or matrix can be made of or include agents which provide formetered or sustained release of the therapeutic agents.

In preventing and/or treating cardiovascular diseases or disorders, thenitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolite of nebivolol and/or nebivolol, and, optionally,at least one compound that donates, transfers or releases nitric oxideand/or stimulates the endogenous production of NO or EDRF in vivo and/oris a substrate for nitric oxide synthase and/or at least one therapeuticagent and/or at least one nitrosated and/or nitrosylated therapeuticagent, can be administered directly to the damaged vascular surfaceintravenously by using an intraarterial or intravenous catheter,suitable for delivery of the compounds to the desired location. Thelocation of damaged arterial surfaces is determined by conventionaldiagnostic methods, such as X-ray angiography, performed using routineand well-known methods available to one skilled in the art. In addition,administration of the nitrosated and/or nitrosylated nebivolol, and/ornitrosated and/or nitrosylated metabolite of nebivolol and/or nebivolol,and, optionally, NO donors, therapeutic agents and/or nitrosated and/ornitrosylated therapeutic agents, using an intraarterial or intravenouscatheter is performed using routine methods well known to one skilled inthe art. Typically, the compound or composition is delivered to the siteof angioplasty through the same catheter used for the primary procedure,usually introduced to the carotid or coronary artery at the time ofangioplasty balloon inflation. The nitrosated and/or nitrosylatednebivolol and/or nitrosated and/or nitrosylated metabolite of nebivololand/or nebivolol, and, optionally, NO donors, therapeutic agents andnitrosated and/or nitrosylated therapeutic agents, slowly decompose atbody temperature over a prolonged period of time releasing nitric oxideat a rate effective to prevent and/or treat cardiovascular diseases ordisorders including, for example, restenosis.

When administered in vivo, the compounds and compositions of theinvention can be administered in combination with pharmaceuticallyacceptable carriers and in dosages described herein. When the compoundsand compositions of the invention are administered as a mixture of atleast one nitrosated and/or nitrosylated nebivolol or at least onenitrosated and/or nitrosylated metabolite of nebivolol or nebivolol orat least one metabolite of nebivolol and at least one nitric oxidedonor, or at least one therapeutic agent or at least one nitrosatedand/or nitrosylated therapeutic agent, they can also be used incombination with one or more additional therapeutic agents which areknown to be effective against the specific disease state targeted fortreatment. The nitric oxide donors and/or therapeutic agents can beadministered simultaneously with, subsequently to, or prior toadministration of nebivolol, including those that are substituted withone or more NO and/or NO₂ groups, and/or other additional compounds.

The compounds and compositions of the invention can be administered byany available and effective delivery system including, but not limitedto, orally, bucally, parenterally, by inhalation spray, by topicalapplication, by injection, transdermally, or rectally (e.g., by the useof suppositories) in dosage unit formulations containing conventionalnontoxic pharmaceutically acceptable carriers, adjuvants, and vehicles,as desired. Parenteral includes subcutaneous injections, intravenous,intramuscular, intrasternal injection, or infusion techniques.

Topical compound administration, which is known to one skilled in theart, involves the delivery of pharmaceutical compounds via percutaneouspassage of the compound into the systemic circulation of the patient.Topical administration can also involve the use of transdermaladministration such as transdermal patches or iontophoresis devices.Other components can be incorporated into the transdermal patches aswell. For example, compositions and/or transdermal patches can beformulated with one or more preservatives or bacteriostatic agentsincluding, but not limited to, methyl hydroxybenzoate, propylhydroxybenzoate, chlorocresol, benzalkonium chloride, and the like.Dosage forms for topical administration of the compounds andcompositions can include creams, pastes, sprays, lotions, gels,ointments, eye drops, nose drops, ear drops, and the like. In suchdosage forms, the compositions of the invention can be mixed to formwhite, smooth, homogeneous, opaque cream or lotion with, for example,benzyl alcohol 1% or 2% (wt/wt) as a preservative, emulsifying wax,glycerin, isopropyl palmitate, lactic acid, purified water and sorbitolsolution. In addition, the compositions can contain polyethylene glycol400. They can be mixed to form ointments with, for example, benzylalcohol 2% (wt/wt) as preservative, white petrolatum, emulsifying wax,and tenox II (butylated hydroxyanisole, propyl gallate, citric acid,propylene glycol). Woven pads or rolls of bandaging material, e.g.,gauze, can be impregnated with the compositions in solution, lotion,cream, ointment or other such form can also be used for topicalapplication. The compositions can also be applied topically using atransdermal system, such as one of an acrylic-based polymer adhesivewith a resinous crosslinking agent impregnated with the composition andlaminated to an impermeable backing.

Solid dosage forms for oral administration can include capsules,tablets, effervescent tablets, sustain release tablets, sustain releasecapsules, chewable tablets, pills, powders, sachets, granules and gels.In such solid dosage forms, the active compounds can be admixed with atleast one inert diluent such as sucrose, lactose or starch. Such dosageforms can also comprise, as in normal practice, additional substancesother than inert diluents, e.g., lubricating agents such as magnesiumstearate. In the case of capsules, tablets, effervescent tablets, andpills, the dosage forms can also comprise buffering agents. Soft gelatincapsules can be prepared to contain a mixture of the active compounds orcompositions of the invention and vegetable oil. Hard gelatin capsulescan contain granules of the active compound in combination with a solid,pulverulent carrier such as lactose, saccharose, sorbitol, mannitol,potato starch, corn starch, amylopectin, cellulose derivatives ofgelatin. Tablets and pills can be prepared with enteric coatings.

Liquid dosage forms for oral administration can include pharmaceuticallyacceptable emulsions, solutions, suspensions, syrups, and elixirscontaining inert diluents commonly used in the art, such as water. Suchcompositions can also comprise adjuvants, such as wetting agents,emulsifying and suspending agents, and sweetening, flavoring, andperfuming agents.

Suppositories for vaginal or rectal administration of the compounds andcompositions of the invention can be prepared by mixing the compounds orcompositions with a suitable nonirritating excipient such as cocoabutter and polyethylene glycols which are solid at room temperature butliquid at body temperature, such that they will melt and release thedrug.

Injectable preparations, for example, sterile injectable aqueous oroleaginous suspensions can be formulated according to the known artusing suitable dispersing agents, wetting agents and/or suspendingagents. The sterile injectable preparation can also be a sterileinjectable solution or suspension in a nontoxic parenterally acceptablediluent or solvent, for example, as a solution in 1,3-butanediol. Amongthe acceptable vehicles and solvents that can be used are water,Ringer's solution, and isotonic sodium chloride solution. Sterile fixedoils are also conventionally used as a solvent or suspending medium.

The compositions of this invention can further include conventionalexcipients, i.e., pharmaceutically acceptable organic or inorganiccarrier substances suitable for parenteral application which do notdeleteriously react with the active compounds. Suitable pharmaceuticallyacceptable carriers include, for example, water, salt solutions,alcohol, vegetable oils, polyethylene glycols, gelatin, lactose,amylose, magnesium stearate, talc, surfactants, silicic acid, viscousparaffin, perfume oil, fatty acid monoglycerides and diglycerides,petroethral fatty acid esters, hydroxymethyl-cellulose,polyvinylpyrrolidone, and the like. The pharmaceutical preparations canbe sterilized and if desired, mixed with auxiliary agents, e.g.,lubricants, preservatives, stabilizers, wetting agents, emulsifiers,salts for influencing osmotic pressure, buffers, colorings, flavoringand/or aromatic substances and the like which do not deleteriously reactwith the active compounds. For parenteral application, particularlysuitable vehicles consist of solutions, preferably oily or aqueoussolutions, as well as suspensions, emulsions, or implants. Aqueoussuspensions may contain substances that increase the viscosity of thesuspension and include, for example, sodium carboxymethyl cellulose,sorbitol and/or dextran. Optionally, the suspension may also containstabilizers.

Solvents useful in the practice of this invention includepharmaceutically acceptable, water-miscible, non-aqueous solvents. Inthe context of this invention, these solvents should be taken to includesolvents that are generally acceptable for pharmaceutical use,substantially water-miscible, and substantially non-aqueous. Preferably,these solvents are also non-phthalate plasticizer leaching solvents, sothat, when used in medical equipment, they substantially do not leachphthalate plasticizers that may be present in the medical equipment.More preferably, the pharmaceutically-acceptable, water-miscible,non-aqueous solvents usable in the practice of this invention include,but are not limited to, N-methylpyrrolidone (NMP); propylene glycol;ethyl acetate; dimethyl sulfoxide; dimethyl acetamide; benzyl alcohol;2-pyrrolidone; benzyl benzoate; C₂₋₆ alkanols; 2-ethoxyethanol; alkylesters such as 2-ethoxyethyl acetate, methyl acetate, ethyl acetate,ethylene glycol diethyl ether, or ethylene glycol dimethyl ether;(S)-(−)-ethyl lactate; acetone; glycerol; alkyl ketones such asmethylethyl ketone or dimethyl sulfone; tetrahydrofuran; cyclic alkylamides such as caprolactam; decylmethylsulfoxide; oleic acid; aromaticamines such as N,N-diethyl-m-toluamide; or1-dodecylazacycloheptan-2-one.

The most preferred pharmaceutically-acceptable, water-miscible,non-aqueous solvents are N-methylpyrrolidone (NMP), propylene glycol,ethyl acetate, dimethyl sulfoxide, dimethyl acetamide, benzyl alcohol,2-pyrrolidone, or benzyl benzoate. Ethanol may also be used as apharmaceutically-acceptable, water-miscible, non-aqueous solventaccording to the invention, despite its negative impact on stability.Additionally, triacetin may also be used as apharmaceutically-acceptable, water-miscible, non-aqueous solvent, aswell as functioning as a solubilizer in certain circumstances. NMP maybe available as PHARMASOLVE® from International Specialty Products(Wayne, N.J.). Benzyl alcohol may be available from J. T. Baker, Inc.Ethanol may be available from Spectrum, Inc. Triacetin may be availablefrom Mallinkrodt, Inc.

The compositions of this invention can further include solubilizers.Solubilization is a phenomenon that enables the formation of a solution.It is related to the presence of amphiphiles, that is, those moleculesthat have the dual properties of being both polar and non-polar in thesolution that have the ability to increase the solubility of materialsthat are normally insoluble or only slightly soluble, in the dispersionmedium. Solubilizers often have surfactant properties. Their functionmay be to enhance the solubility of a solute in a solution, rather thanacting as a solvent, although in exceptional circumstances, a singlecompound may have both solubilizing and solvent characteristics.Solubilizers useful in the practice of this invention include, but arenot limited to, triacetin, polyethylene glycols (such as, for example,PEG 300, PEG 400, or their blend with 3350, and the like), polysorbates(such as, for example, Polysorbate 20, Polysorbate 40, Polysorbate 60,Polysorbate 65, Polysorbate 80, and the like), poloxamers (such as, forexample, Poloxamer 124, Poloxamer 188, Poloxamer 237, Poloxamer 338,Poloxamer 407, and the like), polyoxyethylene ethers (such as, forexample, Polyoxyl 2 cetyl ether, Polyoxyl 10 cetyl ether, and Polyoxyl20 cetyl ether, Polyoxyl 4 lauryl ether, Polyoxyl 23 lauryl ether,Polyoxyl 2 oleyl ether, Polyoxyl 10 oleyl ether, Polyoxyl 20 oleylether, Polyoxyl 2 stearyl ether, Polyoxyl 10 stearyl ether, Polyoxyl 20stearyl ether, Polyoxyl 100 stearyl ether, and the like),polyoxylstearates (such as, for example, Polyoxyl 30 stearate, Polyoxyl40 stearate, Polyoxyl 50 stearate, Polyoxyl 100 stearate, and the like),polyethoxylated stearates (such as, for example, polyethoxylated12-hydroxy stearate, and the like), and Tributyrin.

Other materials that may be added to the compositions of the inventioninclude cyclodextrins, and cyclodextrin analogs and derivatives, andother soluble excipients that could enhance the stability of theinventive composition, maintain the product in solution, or prevent sideeffects associated with the administration of the inventive composition.Cyclodextrins may be available as ENCAPSIN® from JanssenPharmaceuticals.

The composition, if desired, can also contain minor amounts of wettingagents, emulsifying agents and/or pH buffering agents. The compositioncan be a liquid solution, suspension, emulsion, tablet, pill, capsule,sustained release formulation, or powder. The composition can beformulated as a suppository, with traditional binders and carriers suchas triglycerides. Oral formulations can include standard carriers suchas pharmaceutical grades of mannitol, lactose, starch, magnesiumstearate, sodium saccharine, cellulose, magnesium carbonate, and thelike.

Various delivery systems are known and can be used to administer thecompounds or compositions of the invention, including, for example,encapsulation in liposomes, microbubbles, emulsions, microparticles,microcapsules, nanoparticles, and the like. The required dosage can beadministered as a single unit or in a sustained release form.

The bioavailabilty of the compositions can be enhanced by micronizationof the formulations using conventional techniques such as grinding,milling, spray drying and the like in the presence of suitableexcipients or agents such as phospholipids or surfactants.

Sustained release dosage forms of the invention may comprisemicroparticles and/or nanoparticles having a therapeutic agent dispersedtherein or may comprise the therapeutic agent in pure, preferablycrystalline, solid form. For sustained release administration,microparticle dosage forms comprising pure, preferably crystalline,therapeutic agents are preferred. The therapeutic dosage forms of thisaspect of the invention may be of any configuration suitable forsustained release. Preferred sustained release therapeutic dosage formsexhibit one or more of the following characteristics: microparticles(e.g., from about 0.5 micrometers to about 100 micrometers in diameter,preferably about 0.5 to about 2 micrometers; or from about 0.01micrometers to about 200 micrometers in diameter, preferably from about0.5 to about 50 micrometers, and more preferably from about 2 to about15 micrometers) or nanoparticles (e.g., from about 1.0 nanometer toabout 1000 nanometers in diameter, preferably about 50 to about 250nanometers; or from about 0.01 nanometer to about 1000 nanometers indiameter, preferably from about 50 to about 200 nanometers), freeflowing powder structure; biodegradable structure designed to biodegradeover a period of time between from about 0.5 to about 180 days,preferably from about 1 to 3 to about 150 days, more preferably fromabout 3 to about 180 days, and most preferably from about 10 to about 21days; or non-biodegradable structure to allow the therapeutic agentdiffusion to occur over a time period of between from about 0.5 to about180 days, more preferably from about 30 to about 120 days; or from about3 to about 180 days, more preferably from about 10 to about 21 days;biocompatible with target tissue and the local physiological environmentinto which the dosage form to be administered, including yieldingbiocompatible biodegradation products; facilitate a stable andreproducible dispersion of therapeutic agent therein, preferably to forma therapeutic agent-polymer matrix, with active therapeutic agentrelease occurring by one or both of the following routes: (1) diffusionof the therapeutic agent through the dosage form (when the therapeuticagent is soluble in the shaped polymer or polymer mixture defining thedimensions of the dosage form); or (2) release of the therapeutic agentas the dosage form biodegrades; and/or for targeted dosage forms,capability to have, preferably, from about 1 to about 10,000 bindingprotein/peptide to dosage form bonds and more preferably, a maximum ofabout 1 binding peptide to dosage form bond per 150 square angstroms ofparticle surface area. The total number of binding protein/peptide todosage form bonds depends upon the particle size used. The bindingproteins or peptides are capable of coupling to the particles of thetherapeutic dosage form through covalent ligand sandwich or non-covalentmodalities as set forth herein.

Nanoparticle sustained release therapeutic dosage forms are preferablybiodegradable and, optionally, bind to the vascular smooth muscle cellsand enter those cells, primarily by endocytosis. The biodegradation ofthe nanoparticles occurs over time (e.g., 30 to 120 days; or 10 to 21days) in prelysosomic vesicles and lysosomes. Preferred largermicroparticle therapeutic dosage forms of the invention release thetherapeutic agents for subsequent target cell uptake with only a few ofthe smaller microparticles entering the cell by phagocytosis. Apractitioner in the art will appreciate that the precise mechanism bywhich a target cell assimilates and metabolizes a dosage form of theinvention depends on the morphology, physiology and metabolic processesof those cells. The size of the particle sustained release therapeuticdosage forms is also important with respect to the mode of cellularassimilation. For example, the smaller nanoparticles can flow with theinterstitial fluid between cells and penetrate the infused tissue. Thelarger microparticles tend to be more easily trapped interstitially inthe infused primary tissue, and thus are useful to deliveranti-proliferative therapeutic agents.

Preferred sustained release dosage forms of the invention comprisebiodegradable microparticles or nanoparticles. More preferably,biodegradable microparticles or nanoparticles are formed of a polymercontaining matrix that biodegrades by random, nonenzymatic, hydrolyticscissioning to release therapeutic agent, thereby forming pores withinthe particulate structure.

The compounds and compositions of the invention can be formulated aspharmaceutically acceptable salts. Pharmaceutically acceptable saltsinclude, for example, alkali metal salts and addition salts of freeacids or free bases. The nature of the salt is not critical, providedthat it is pharmaceutically-acceptable. Suitablepharmaceutically-acceptable acid addition salts may be prepared from aninorganic acid or from an organic acid. Examples of such inorganic acidsinclude, but are not limited to, hydrochloric, hydrobromic, hydroiodic,nitrous (nitrite salt), nitric (nitrate salt), carbonic, sulfuric,phosphoric acid, and the like. Appropriate organic acids include, butare not limited to, aliphatic, cycloaliphatic, aromatic, heterocyclic,carboxylic and sulfonic classes of organic acids, such as, for example,formic, acetic, propionic, succinic, glycolic, gluconic, lactic, malic,tartaric, citric, ascorbic, glucuronic, maleic, fumaric, pyruvic,aspartic, glutamic, benzoic, anthranilic, mesylic, salicylic,p-hydroxybenzoic, phenylacetic, mandelic, embonic (pamoic),methanesulfonic, ethanesulfonic, benzenesulfonic, pantothenic,toluenesulfonic, 2-hydroxyethanesulfonic, sulfanilic, stearic, algenic,β-hydroxybutyric, cyclohexylaminosulfonic, galactaric and galacturonicacid and the like. Suitable pharmaceutically-acceptable base additionsalts include, but are not limited to, metallic salts made fromaluminum, calcium, lithium, magnesium, potassium, sodium and zinc ororganic salts made from primary, secondary and tertiary amines, cyclicamines, N,N′-dibenzylethylenediamine, chloroprocaine, choline,diethanolamine, ethylenediamine, meglumine (N-methylglucamine) andprocaine and the like. All of these salts may be prepared byconventional means from the corresponding compound by reacting, forexample, the appropriate acid or base with the compound.

While individual needs may vary, determination of optimal ranges foreffective amounts of the compounds and/or compositions is within theskill of the art. Generally, the dosage required to provide an effectiveamount of the compounds and compositions, which can be adjusted by oneof ordinary skill in the art, will vary depending on the age, health,physical condition, sex, diet, weight, extent of the dysfunction of therecipient, frequency of treatment and the nature and scope of thedysfunction or disease, medical condition of the patient, the route ofadministration, pharmacological considerations such as the activity,efficacy, pharmacokinetic and toxicology profiles of the particularcompound used, whether a drug delivery system is used, and whether thecompound is administered as part of a drug combination.

The usual doses of nebivolol (including nitrosated and/or nitrosylatednebivolol, nitrosated and/or nitrosylated metabolites of nebivolol, andmetabolites of nebivolol) for the treating and/or preventing vasculardiseases characterized by nitric oxide insufficiency; and for treatingand/or preventing Raynaud's syndrome is approximately 0.1 mg to about 10mg per day, preferably about 5 mg per day, administered as a single doseonce a day; in multiple doses several times throughout the day; or in asustained-release formulation or as a transdermal patch.

The doses of nitric oxide donors in the pharmaceutical composition willbe dependent on the specific nitric oxide donor compound and the mode ofadministration. For example, when isosorbide dinitrate is the orallyadministered nitric oxide donor, it can be administered in an amount ofabout 5 milligrams per day to about 200 milligrams per day. In a moreparticular embodiment, the isosorbide dinitrate can be administered inan amount of about 20 milligrams per day to about 160 milligrams perday. In an even more particular embodiment, the isosorbide dinitrate canbe administered in an amount of about 40 milligrams one to four timesper day. When isosorbide mononitrate is the orally administered nitricoxide donor, it can be administered in an amount of about 5 milligramsper day to about 120 milligrams per day. In a more particularembodiment, the isosorbide mononitrate can be administered in an amountof about 15 milligrams per day to about 100 milligrams per day. In aneven more particular embodiment, the isosorbide mononitrate can beadministered in an amount of about 20 milligrams one to four times perday. The particular amounts of isosorbide dinitrate and/or isosorbidemononitrate can be administered as a single dose once a day; or inmultiple doses several times throughout the day; or as asustained-release oral formulation; or as a transdermal sustainedrelease patch.

The dose of nitric oxide donor in the composition will be dependent onthe specific nitric oxide donor compound and the mode of administration.For example, when L-arginine is the orally administered nitric oxidedonor, it can be administered in an amount of about 3 grams to about 15grams to provide a plasma level in the range of about 0.2 mM to about 30mM.

The doses of the antioxidant in the pharmaceutical composition will bedependent on the specific antioxidant compound and the mode ofadministration. For example when hydralazine is the administeredantioxidant, it can be administered in an amount of about 30 milligramsper day to about 400 milligrams per day. In a more particularembodiment, the hydralazine hydrochloride can be administered in anamount of about 50 milligrams per day to about 300 milligrams per day.In an even more particular embodiment, the hydralazine hydrochloride canbe administered in an amount of about 75 milligrams once to four timesper day. The particular amounts of hydralazine can be administered as asingle dose once a day; or in multiple doses several times throughoutthe day; or as a sustained-release oral formulation; or as a transdermalsustained release patch.

The nitrosated and/or nitrosylated nebivolol and/or nitrosated and/ornitrosylated metabolites of nebivolol of the invention are used at doseranges and over a course of dose regimen and are administered in thesame or substantially equivalent vehicles/carrier by the same orsubstantially equivalent as their non-nitrosated/nitrosylatedcounterparts. The nitrosated and/or nitrosylated compounds of theinvention can also be used in lower doses and in less extensive regimensof treatment. The amount of active ingredient that can be combined withthe carrier materials to produce a single dosage form will varydepending upon the host treated and the particular mode ofadministration, and is within the skill in the art.

The invention also provides pharmaceutical kits comprising one or morecontainers filled with one or more of the ingredients of thepharmaceutical compounds and/or compositions of the invention,including, nebivolol, optionally substituted with at least one NO and/orNO₂ group, one or more metabolites of nebivolol, optionally substitutedwith one or more NO and/or NO₂ groups, and one or more of the NO donors,and one or more antioxidants described herein. Such kits can alsoinclude, for example, other compounds and/or compositions (e.g.,diuretics, digoxin, compounds used to treat cardiovascular diseases,therapeutic agents, permeation enhancers, lubricants, and the like), adevice(s) for administering the compounds and/or compositions, andwritten instructions in a form prescribed by a governmental agencyregulating the manufacture, use or sale of pharmaceuticals or biologicalproducts, which instructions can also reflects approval by the agency ofmanufacture, use or sale for human administration.

The disclosure of each patent, patent application and publication citedor described in the specification is hereby incorporated by referenceherein in its entirety.

Although the invention has been set forth in detail, one skilled in theart will appreciate that numerous changes and modifications may be madewithout departing from the spirit and scope of the invention.

1. A composition comprising a compound of Formula (I), Formula (IV) orFormula (V), a stereoisomer thereof or a pharmaceutically acceptablesalt thereof: wherein the compound of Formula (I) is:

wherein: D is hydrogen, Q, K or R₅; R₅ is:

D₁ is hydrogen or R₅; D₂ is hydrogen, Q or K; Q is —NO or —NO₂; K is—W_(a)-E_(b)—(C(R_(e))(R_(f)))_(p)-E_(c)—(C(R_(e))(R_(f)))_(x)—W_(d)—(C(R_(e))(R_(f)))_(y)—W_(i)-E_(j)—W_(g)—(C(R_(e))(R_(f)))_(z)-T-Q;a, b, c, d, g, i and j are each independently an integer from 0 to 3; p,x, y and z are each independently an integer from 0 to 10; W at eachoccurrence is independently —C(O)—, —C(S)—, -T-,—(C(R_(e))(R_(f)))_(h)—, an alkyl group, an aryl group, a heterocyclicring, an arylheterocyclic ring, or —(CH₂CH₂O)_(q)—; E at each occurrenceis independently -T-, an alkyl group, an aryl group,—(C(R_(e))(R_(f)))_(h)—, a heterocyclic ring, an arylheterocyclic ring,or —(CH₂CH₂O)_(q)—; h is an integer form 1 to 10; q is an integer from 1to 5; R_(e) and R_(f) are each independently a hydrogen, an alkyl, acycloalkoxy, a halogen, a hydroxy, an hydroxyalkyl, an alkoxyalkyl, anarylheterocyclic ring, an alkylaryl, an alkylcycloalkyl, analkylheterocyclic ring, a cycloalkylalkyl, a cycloalkylthio, acycloalkenyl, an heterocyclicalkyl, an alkoxy, a haloalkoxy, an amino,an alkylamino, a dialkylamino, an arylamino, a diarylamino, analkylarylamino, an alkoxyhaloalkyl, a haloalkoxy, a sulfonic acid, asulfonic ester, an alkylsulfonic acid, an arylsulfonic acid, anarylalkoxy, an alkylthio, an arylthio, a cyano an aminoalkyl, anaminoaryl, an aryl, an arylalkyl, an alkylaryl, a carboxamido, aalkylcarboxamido, an arylcarboxamido, an amidyl, a carboxyl, acarbamoyl, an alkylcarboxylic acid, an arylcarboxylic acid, analkylcarbonyl, an arylcarbonyl, an ester, a carboxylic ester, analkylcarboxylic ester, an arylcarboxylic ester, a haloalkoxy, asulfonamido, an alkylsulfonamido, an arylsulfonamido, an alkylsulfonyl,an alkylsulfonyloxy, an arylsulfonyl, arylsulphonyloxy, a sulfonicester, a urea, a phosphoryl, a nitro, W_(h), -T-Q, or—(C(R_(e))(R_(f)))_(k)-T-Q, or R_(e) and R_(f) taken together with thecarbons to which they are attached form a carbonyl, a methanthial, aheterocyclic ring, a cycloalkyl group, an aryl group, an oxime or abridged cycloalkyl group; k is an integer from 1 to 3; T at eachoccurrence is independently a covalent bond, a carbonyl, an oxygen,—S(O)_(o)— or —N(R_(a))R_(i)—; o is an integer from 0 to 2; R_(a) is alone pair of electrons, a hydrogen or an alkyl group; R_(i) is ahydrogen, an alkyl, an aryl, an alkylcarboxylic acid, an arylcarboxylicacid, an alkylcarboxylic ester, an arylcarboxylic ester, analkylcarboxamido, an arylcarboxamido, an alkylaryl, an alkylsulfinyl, analkylsulfonyl, an alkylsulfonyloxy, an arylsulfinyl, an arylsulfonyl,arylsulphonyloxy, a sulfonamido, a carboxamido, a carboxylic ester, anaminoalkyl, an aminoaryl, —CH₂—C(T-Q)(R_(e))(R_(f)), a bond to anadjacent atom creating a double bond to that atom, —(N₂O₂—)⁻•M⁺, whereinM⁺ is an organic or inorganic cation; with the proviso that the compoundof Formula (I) must contain at least one nitrite, nitrate, thionitriteor thionitrate group; wherein the compounds of Formula (IV) and Formula(V) are:

wherein: R₆ at each occurrence is independently a hydrogen, a hydroxy or—OD; D and D₁ are as defined herein; and with the proviso that thecompounds of Formula (IV) and Formula (V) must contain at least onenitrite, nitrate, thionitrite or thionitrate group; and at least one ofisosorbide mononitrate and/or isosorbide dinitrate or a pharmaceuticallyacceptable salt thereof, and, optionally, at least one antioxidant,wherein the antioxidant is a small-molecule antioxidant, or apharmaceutically acceptable salt thereof, or an antioxidant enzyme. 2.The composition of claim 1, further comprising a pharmaceuticallyacceptable carrier.
 3. The composition of claim 1, wherein theantioxidant enzyme is a superoxide dismutase, a catalase, a glutathioneperoxidase, or a mixture thereof.
 4. The composition of claim 1, whereinthe small-molecule antioxidant is a hydralazine compound of Formula(VI), a glutathione, a vitamin C, a vitamin E, a cysteine, aN-acetyl-cysteine, a β-carotene, an ubiquinone, an ubiquinol-10, atocopherol, a coenzyme Q, or a mixture thereof; wherein the hydralazinecompound of Formula (VI) is:

wherein a, b and c are independently a single or double bond; R₇ and R₈are each independently a hydrogen, an alkyl, an ester or a heterocyclicring; R₉ and R₁₀ are each independently a lone pair of electrons or ahydrogen; with the proviso that at least one of R₇, R₈, R₉ and R₁₀ isnot a hydrogen.
 5. The composition of claim 4, wherein the hydralazinecompound is budralazine, cadralazine, dihydralazine, endralazine,hydralazine, pildralazine or todralazine or a pharmaceuticallyacceptable salt thereof.
 6. The composition of claim 5, wherein thehydralazine compound is hydralazine hydrochloride.
 7. A method oftreating hypertension in a patient in need thereof comprisingadministering a therapeutically effective amount of the composition ofclaim
 2. 8. The method of claim 7, wherein the composition isadministered intravenously, orally, bucally, parenterally, by aninhalation spray, by topical application or transdermally.